OG Summer 2009 PDF

Contents art or science?
Obstetrics:
O&G
Magazine
Available online at:

www.ranzcog.edu.au/publications/oandg
O&G Magazine Advisory Group

Prof Caroline de Costa Council Rep, QLD
Dr Sarah Tout Council Rep, New Zealand
A/Prof Steve Robson Fellows Rep, ACT
Dr John Schibeci Diplomates Rep, NSW
Dr Brett Daniels Trainee Rep, TAS
O&G Magazine Editors
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Julia Serafin
Peter White
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O&G Magazine authorised by
Dr Peter White 2009 The Royal
Australian and New Zealand College
of Obstetricians and Gynaecologists
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Cover image RANZCOG. Birth Atlas, Plate 13.
2 O&G Magazine
Obstetrics: art or science?

11
Editorial: Everyones a critic

Steve Robson
12

Tony Baird
14
Reflections on my initiation into the secret world of complex vaginal birth

Keith Hollebone
17
Complex vaginal deliveries: Why are we still doing them?

Martin Sowter
19
Forceps delivery: Science wears its art on its sleeve

Steve Robson and Caroline de Costa
21
Preventing eclampsia: art or science?

Richard Lewis and Caroline de Costa
22
Standards of antenatal care

Celia Devenish
24
Antenatal classes patient perspectives

Anonymous
25
Non-pharmacological pain management in childbirth

Collated by John Schibeci
29
Planned homebirths in Australia: art, science...or politics?

Andrew Pesce
31
Homebirth transfers at Lismore Base Hospital

Brendan OSullivan, Tony Bushati and Tim Ho
34
A midwifes perspective on homebirth in New Zealand

Cheryl Benn
36
Intrapartum fetal monitoring yesterday, today and tomorrow

Wan Tinn Teh and Stephen Tong
38
Controlling the timing of labour: the role of progesterone and prostaglandins

Toni Welsh
Womens Health
40
Obstetric Management Update: Swine flu in obstetrics

Wade Stedman and Heike Koelzow
43
Gynaecological Management Update: The myth of screening for epithelial

ovarian cancer
Alison Brand
46
Journal Club
Brett Daniels
Obstetrics: art or Contents

science?
RANZCOG Regional Committees
53
New Zealand
Dr John Tait Chair
Kate Bell Executive Officer
Level 3, Alan Burns Insurances House
69 Boulcott Street/PO Box 10 611
Wellington, New Zealand
+64 4 472 4608 (t)
+64 4 472 4609 (f)
kate.bell@ranzcog.org.nz (e)
Q&a: Management of the third stage of labour

Michael Permezel
Medico-legal
58
Informed consent in labour an Australian perspective

Andrew Took
59
Informed consent in labour an Australian perspective

Fleur Dewhurst
60
Informed consent in labour a New Zealand perspective

Denys Court
Australian Capital Territory

Dr Andrew Foote Chair
Deakin Gynaecology Centre
39 Grey Street
Deakin, ACT 2600
+61 2 6273 3102 (t)
+61 2 6273 3002 (f)
muttons@dynamite.com.au (e)
New South Wales
Professor Alec Welsh Chair
Lee Dawson Executive Officer
Suite 4, Level 5, 69 Christie Street
St Leonards, NSW 2065
+61 2 9436 1688 (t)
+61 2 9436 4166 (f)
admin@ranzcog.nsw.edu.au (e)
The College
5
From the President

Ted Weaver
From the CEO

Peter White
47
Meetings Calendar Summer 2009
54
Fetal Surveillance: A Practical Guide a new publication
55
RANZCOG Practice Profile Workforce Survey

Ted Weaver, Valerie Jenkins and Kate Lording
63
MRANZCOG Written Exam February 2009

Jolyon Ford
68
Specialist Obstetrician Locum Scheme (SOLS) Update

Valerie Jenkins
69
Tribute to William Refshauge

Keith Barnes
73
RANZCOG Research Foundation 2010 Scholarships, Fellowships and Grants
70
Obituaries
71
Notice of Deceased Fellows
76
Staff News
76
RANZCOG Womens Health Award
80
O&G Magazine Cumulative Index Vol 7 to Vol 11
Queensland
Dr Paul Howat Chair
Lee-Anne Harris Executive Officer
Unit 22, Level 3, 17 Bowen Bridge Road
HERSTON, Qld 4006
+61 7 3252 3073 (t)
+61 7 3257 2370 (f)
lharris@ranzcog.edu.au (e)
South Australia/Northern Territory
Dr Christine Kirby Chair
Tania Back Executive Officer
1-54 Palmer Place/PO Box 767
North Adelaide, SA 5006
+61 8 8267 4377 (t)
+61 8 8267 5700 (f)
ranzcog.sa.nt@internode.on.net (e)
Tasmania
Dr Stephen Raymond Chair
Hobart Urogynae & Incontinence Clinic
4/44 Argyle Street
Hobart, TAS 7008
+61 3 6223 1596 (t)
+61 3 6223 5281 (f)
rfullert@tassie.net.au (e)
* The next update on College Statements will be published in

O&G Magazine Autumn 2010.
Victoria
Dr Elizabeth Uren Chair
Fran Watson Executive Officer
8 Latrobe Street
Melbourne, VIC 3000
+61 3 9663 5606 (t)
+ 61 3 9662 3908 (f)
vsc@ranzcog.edu.au (e)
Western Australia
Dr Tamara Walters Chair
Janet Davidson Executive Officer
Level 1, 44 Kings Park Road
WEST PERTH, WA 6005/PO Box 6258
EAST PERTH, WA 6892
+61 8 9322 1051 (t)
+61 8 6263 4432 (f)
ranzcogwa@westnet.com.au (e)
The Royal Australian and New Zealand

College of Obstetricians
and Gynaecologists
College House
254-260 Albert Street
East Melbourne, Vic 3002
+61 3 9417 1699 (t)
+61 3 9417 0672 (f)
ranzcog@ranzcog.edu.au (e)
www.ranzcog.edu.au (w)
President
Dr Ted Weaver
Vice Presidents
Prof Michael Permezel
Dr Rupert Sherwood
Dr Digby Ngan Kee
Honorary Secretary
Dr Gino Pecoraro
Honorary Treasurer
Dr Bernadette White
Chief Executive Officer
Dr Peter White
Vol 11 No 4 Summer 2009 3
Single injection for lasting prevention

of postpartum haemorrhage following
elective caesarean section1,2,3
For further information please contact us at
enquiries@ferring.com or call Freephone 1800 33 77 46
Minimum Product Information
DURATOCIN (Carbetocin Injection): INDICATIONS: DURATOCIN is indicated for the prevention of uterine atony and excessive bleeding following delivery
of the infant by elective caesarean section under epidural or spinal anaesthesia. DURATOCIN is an oxytocic that reduces the need for additional oxytocics.
Duratocin has not been studied in women at high risk of postpartum haemorrhage, for example with parity greater than 4, with hypertension, following
especially prolonged labour, or with general anaesthesia. DOSAGE AND ADMINISTRATION: A single intravenous dose of 100g (1 mL) of DURATOCIN
(carbetocin injection) is administered by bolus injection, slowly over 1 minute, only when delivery of the infant has been completed by caesarean section
under epidural or spinal anaesthesia. DURATOCIN can be administered either before or after delivery of the placenta. DURATOCIN is to be used as a single
dose only. CONTRAINDICATIONS: Because of its long duration of action relative to oxytocin, uterine contractions produced by carbetocin cannot be stopped
by simply discontinuing the medication. Therefore carbetocin should not be administered prior to delivery of the infant for any reason, including elective or
medical induction of labour. Inappropriate use of carbetocin during pregnancy could theoretically mimic the symptoms of oxytocin overdosage, including
hyperstimulation of the uterus with strong (hypertonic) or prolonged (tetanic) contractions, tumultuous labour, uterine rupture, cervical and vaginal lacerations,
postpartum haemorrhage, utero-placental hypoperfusion and variable deceleration of foetal heart, foetal hypoxia, hypercapnia, or death. Carbetocin should
not be used in patients with a history of hypersensitivity to oxytocin or carbetocin. Carbetocin should not be used in patients with vascular disease, especially
coronary artery disease, except with extreme caution. Carbetocin is not intended for use in children. PRECAUTIONS: Some patients may not have an
adequate uterine contraction after a single injection of DURATOCIN (carbetocin injection). In these patients, administration of DURATOCIN should not be
repeated and more aggressive treatment with additional doses of other available uterotonic drugs like oxytocin or ergometrine is warranted. In cases of
persistent bleeding, the presence of retained placental fragments, coagulopathy, or trauma to the genital tract should be ruled out. DURATOCIN is currently
not indicated in emergency caesarean section or after vaginal delivery. DURATOCIN is not recommended for use in elderly patients. Although no cases of
partial retention or trapping of the placenta have been reported, this remains a theoretical possibility if the drug is administered before delivery of the placenta.
Significant antidiuretic effect is not anticipated and has not been demonstrated at the recommended dose but, as carbetocin is closely related in structure to
oxytocin, hyponatraemia and water intoxication should be considered in relevant clinical situations. Carbetocin should be used cautiously in the presence of
epilepsy, migraine, asthma or any state in which a rapid addition to extracellular water may produce hazard for an already overburdened system. Patients with
eclampsia and pre-eclampsia should be monitored for changes in blood pressure. ADVERSE REACTIONS: The adverse events observed with carbetocin
during the clinical trials were of the same type and frequency as the adverse events observed with oxytocin when administered after caesarean section
under epidural or spinal anaesthesia. Intravenous carbetocin was frequently (10-40% of patients) associated with nausea, abdominal pain, pruritis, flushing,
vomiting, feeling of warmth, hypotension, headache and tremor. As most of these reactions also occurred in patients treated with placebo, it is likely that many
were associated with caesarean section, spinal or epidural anaesthesia or drugs used during the procedure. Infrequent adverse events (1-5% of patients)
included back pain, dizziness, metallic taste, anaemia, sweating, chest pain, dyspnoea, chills, tachycardia and anxiety. Please refer to the Approved Product
Information for events reported in clinical studies. Approved PI last amended Oct 2007 available from Ferring Pharmaceuticals.
PBS Information: This product is not listed on the PBS.

Please review Product Information before prescribing.
References: 1. Boucher, M et al. J Perinatol 1998; 18:202 2. Dansereau, J et al. Am J Obstet Gynecol 1999, 180:670-6 3. DURATOCIN Product Information
Suite 2B, Level 2, 802 Pacific Highway Gordon NSW 2072

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DUR/1009/1
The College
From the President

T
Dr Ted Weaver
President
his will be the final Presidents report

for 2009 and it is sobering for me to
realise that this represents the halfway
point in the Sixth RANZCOG Councils
term. Surveying the Councils progress,
I feel some empathy with Othello, who
mused, There are many events in the
womb of time which will be delivered.
There are a number of significant issues
being considered by Council at the
present time and I hope that they will
be resolved by the end of this Councils
term in November 2010. Some of these
issues are highlighted in this report.
It is fitting to start with a quote from

Shakespeare for this O&G Magazine column, as the theme for
this seasons edition is Obstetrics: Art or science? Obstetricians
are often featured in a negative way in the media because of their
ready recourse to caesarean section for any perceived obstetric
problem and there have been concerns expressed that some of the
art of obstetrics has been lost. This edition of O&G Magazine is
thus timely. I would like to thank all those who contributed to O&G
Magazine in 2009. The magazine presents a snapshot of various
aspects of our specialty and practice and it would not flourish in the
way that it has without the generous contributions of many different
authors.
Samoa was hit by a tsunami at the end of September 2009.
RANZCOG, through its Asia Pacific program, has a number of
links with Samoa. Fortunately, the major maternity services in
Samoa were not greatly affected by the tsunami, though there
were obviously extraordinary demands placed on the hospital
services because of people injured in the wake of the tidal wave.
The College contacted the obstetric and gynaecological services
in Samoa offering relief and we continue to be in contact with our
Samoan colleagues.
In early October, I attended the FIGO meeting in Cape Town, South
Africa. It was attended by over 9000 delegates. The breadth of the
scientific program was enormous, with up to six concurrent sessions
at any one time, ranging from cutting-edge clinical and scientific
research, to maternity problems in the developing world, to medicopolitical debate about safe motherhood provision. The meeting itself
was well-run in an attractive venue and it was pleasing to see about
70 Fellows from Australia and New Zealand in attendance.
Elections have been held for the next Executive Board of FIGO and
Professor Sir Sabaratnam Arulkumaran, the current President of
RCOG, and a recently conferred Honorary Fellow of RANZCOG,
was elected as President-elect. Professor Ian Fraser was elected for
a second term as Honorary Secretary. On behalf of RANZCOG, I
would like to congratulate both of these Fellows for attaining such
high office and look forward to RANZCOG working closely with
them to further FIGOs aims in our region.
Professor Dorothy Shaw relinquished the Presidency of FIGO to
Professor Gamal Serour of Egypt. He will hold office until 2012. In
his Presidents address, he outlined FIGOs policies and priorities
for the next three years. These include:
Continuing its leading advocacy, partnership and commitment
to promote the rights and access of women to reproductive and
sexual health services;
Working to reduce maternal mortality including unsafe abortions;

Continuing the fight against violence towards women and
harmful practices; and
Establishing an Education Training and Capacity Building
Committee. It is intended that this group would work with
member societies in developed countries, to get them to partner
with developing countries, in order to build the capacity of those
countries own O and G societies.
The FIGO meeting provided a great opportunity to meet with
representatives of other O and G societies, to discuss issues
regarding workforce training and capacity-building in developing
countries, and to highlight to others the plight of countries in our
region that need international help, such as Papua New Guinea
and the smaller islands in the Pacific.
The governance review undertaken by a specially convened
Council committee is nearing completion. At the July 2009 Council
meeting, a forum was held on the proposed changes to College
governance. Much useful feedback was obtained from this forum
and many of those changes have been incorporated into what could
be the final governance review document. This was circulated to
Councillors in the first week of November. A second Council forum
will be held in November during Council week, with a view towards
obtaining Council approval for the proposed governance changes.
If Council votes for the changes, then the changes will be voted
on in a plebiscite of all Fellows, to be held in early February 2010.
If approved, then the Seventh RANZCOG Council, which is due
to be elected next year, will be elected under the new governance
arrangements. The proposed new arrangements would lead to a
much more streamlined and better governance arrangement for
the College, with better communication and links between central
College and the regions.
There is still much activity in the maternity services area in both
Australia and New Zealand. As part of the proposed Roxon
maternity reforms introduced into Federal Parliament in June 2009
and which are due to go to the Senate when Parliament resumes
sitting in mid-November, there have been a number of committees
convened to work out the details of how the proposed collaborative
care models involving eligible midwives will work, and which
midwives will be deemed eligible. These midwives will be able to
work within verifiable collaborative models of maternity care and
will be able to claim Medicare benefits for doing so.
The Government has convened a Maternity Services Advisory Group
(MSAG), which is a multidisciplinary group to advise Government
on these issues. There are also a number of specialised groups
underpinning the work of MSAG, who are working out models
of care, proposed changes to the Medicare Benefits Schedule
(MBS) and Pharmamceutical Benefits Schedule (PBS), and how to
determine which midwives will be deemed eligible.
A National Health and Medical Research Council (NH&MRC) group
has also been formed, which has written a guidance document for
the proposed changes. This is an evidence-based document, based
on extensive literature search around collaboration in maternity
care. The Department of Health and Ageing asked that the
guidance document focus on the following:
A definition of collaborative care;
Principles for collaborative maternity care;
Delineation of roles, responsibilities and communication lines to
ensure collaboration takes place;
The College
Establishing and maintaining core protocols and procedures;
Monitoring, evaluation and review of service arrangements; and
Case studies.
Once the guidance is finalised, it is to be presented and discussed
at an inter-professional forum in Canberra on 10 December 2009.
The Government has developed a number of different item
numbers for use by midwives, but is still grappling with a number
of issues, such as the insurance status of women who are cared
for by a midwife and subsequently attend a public hospital for
birth. Very basic questions such as Will they be deemed public
or private patients? remain unanswered by Government, which
makes planning for new maternity care models difficult. There are
also many questions about how many obstetricians will engage
with eligible midwives in providing collaborative care programs for
women, and how to engage the obstetric workforce, given that they,
unlike eligible midwives, have no obligation to collaborate.
Thus, there is still no certainty about a number of different issues
in this area, though they should be clarified by early 2010. I will
ensure that the Fellowship is well informed regarding these possible
changes to the way that we practise maternity care in Australia.
In New Zealand, the Health Minister, the Hon Tony Ryall, has
embarked upon a review of health services. He has made a number
of speeches outlining possible changes, though his comments have
been short on detail about any changes to maternity services.
It is hoped that a number of the documents that have been
developed for collaborative care in Australia will prove to be useful
in the New Zealand maternity setting.
The Honours Committee of the College has granted an Honorary
Fellowship to Professor Ian Frazer for his work in the development
of a vaccine against human papilloma virus. Clearly, this is a
significant advance in womens health and ranks with other major
advances in womens health, such as the synthesis of oxytocin and
the advent of antibiotics in saving womens lives. Professor Frazer
was awarded his Honorary Fellowship during November Council
week.
The National Registration and Accreditation Scheme is slowly
maturing. Bill B, which is the second piece of enabling legislation
for the scheme was introduced into the Queensland Parliament and
was subsequently passed. Bill C, the third piece of the legislation,
has already been introduced into the Victorian and New South
Wales parliaments. The College is still supportive of a National
Registration Scheme, but has opposed vigorously the accreditation
provisions contained within earlier drafts of the legislation. This
scheme as proposed now makes it much less likely that ministers
will have the power to accredit specialist medical practitioners and
a separate specialist register from the general register is a welcome
development.
One of the principle jobs of RANZCOG is the training of the
future obstetric and gynaecological workforce. To ensure the best
candidates are selected for positions within the Integrated Training
Program (ITP), it is essential that RANZCOG has a proper trainee
selection process, which must be open, transparent and defendable.
Because of the jurisdictional differences between various States in
Australia and New Zealand, there have evolved slight variations
around selection processes in each region.
To ensure that the RANZCOG trainee selection process continues to
meet expected standards, a workshop was held at College House
in early November to examine the selection process and to make
recommendations to Council for the future selection process. There
was a report on this meeting to November Council.
6 O&G Magazine
As it is the halfway point of the Sixth RANZCOG Council, the

Executive Committee will be reviewing the RANZCOG strategic plan
to fine-tune the plan and ensure that we are on target for meeting
the outcomes required in that plan. As a first measure, I have
looked through the plan and found that Executive and Council are
generally on track to achieve the proposed aims.
Clearly, there are many different initiatives in the area of
education, assessment and training that have been discussed
within Executive, other College committee meetings and Council
for about a year now. These initiatives include different methods of
assessment; modular training; the structure of the ITP; recognition
of prior learning; the possibility of streaming of Trainees; and the
recognition that we may have to introduce categories of Fellowship,
as we can perhaps no longer effectively train everyone to do
everything.
All of these major issues, which have the potential to alter the way
we deliver training and also to alter the type of specialist we turn
out at the end of training, need careful consideration, but must be
progressed if we are to have a safe, skilled, flexible workforce in
the future. It is likely that Council will need to convene a working
group from Executive, Education and Assessment, and Training and
Accreditation committees to develop working papers to address
these issues.
I would like to pay tribute to the College House staff who have
done a great job this year in carrying out the work of the College.
In particular, I would like to thank Peter White and the senior
managers for their efforts this year.
I would like to wish all members and others associated with the
College best wishes for the upcoming festive season.
Wishing all
RANZCOG members
a Merry Christmas and a
safe and prosperous
New Year
RANZCOG thanks all members who
contributed to the work of the
College in 2009.
Without your valuable voluntary input,
we couldnt deliver the services that enable
the College to function efficiently and
effectively.
We wish all members a very Merry Christmas
and a safe and prosperous New Year.
The College looks forward to your continuing
support in 2010.
The College
From the CEO

I
t is a personal and professional

privilege to have been given the
opportunity to lead the team whose
task it is to assist those responsible for
the governance of RANZCOG with
the development and implementation
of strategy and operations that enable
RANZCOG to remain a relevant and
effective organisation.
Like the practice of obstetrics, in which

I have no experience, the question has
been much asked and discussed in
Dr Peter White
regard to whether the act of leading
Chief Executive Officer
and managing in such a role is art
or science. As with the theme for this
edition of O&G Magazine, the answer is not clear cut. There is
almost always acknowledgement of the need for a certain amount
of science, but also the realisation that the construct being
discussed is a gestalt phenomenon where the whole is greater
than the sum of the parts. To simply be able to recite appropriate
literature and the contents of how-to manuals is not enough. Like
obstetrics, leading and managing is an intensely human activity
not on the same life and death scale, of course but still on a level
that affects individuals in an organisation on a daily basis and which
must be practised with an eye for the affective components involved.
There are many parallels that can be drawn with the discussions
in medical education relating to assessment when one considers
the evaluation of leadership; assessment of low-level cognitive
competencies is relatively straightforward and most people can tell
you what good, effective leaders should do. At the other end of
the spectrum, the assessment of higher order capacities is more
difficult and the proof is very often in the eating; that is, the mark
of an effective leader, with the management component which
that entails, is really only seen when some sort of performancebased assessment is employed. In simple terms, can someone do
the business, rather than simply talk the talk? Art or science? So
much of human activity increasingly involves a measure of both.
The proportions may vary, but having sufficient of each to perform
effectively under varying conditions may increasingly be what really
matters.
As I write this report, there is the realisation that the term of this
Council is essentially at its half-way point, with arrangements for the
meeting of Council and its committees in full swing, along with the
annual general meetings of both the College and the RANZCOG
Research Foundation. The festive season is approaching and it is
this time, perhaps more than any throughout the year, that provides
a stimulus to reflect on what has occurred through the calendar
year, what is still undecided and what is requiring further resolution
in the coming year.
As always, there has been much activity, both within and outside the
College, since the previous meeting of Council, with developments
such as the passing of Bill B that underpins the National Registration
and Accreditation Scheme (NRAS) and the constitution of the
Australian Health Practitioners Regulation Agency (AHPRA); and the
Medical Board of Australia to facilitate the operation of the scheme.
There has been further activity at government level in relation to
the shape that maternity reforms in Australia will take, while in New
Zealand, as in Australia, there appears much activity at Ministry

level in regard to reform of the overall health sector.
There is particular activity in Australia associated with health
workforce planning and I would encourage members wishing to
gain an overview of the activity to access the website of the National
Health Workforce Taskforce at: www.nhwt.gov.au/ . As part of
the initiatives aimed at accommodating increased postgraduate
vocational trainees in future years, the Commonwealth remains
committed to the investment in funds to encourage specialist
training in expanded settings, therefore, outside the traditional
public teaching hospitals. The program relating to this is now known
as the Specialist Training Program (STP) and, as a result of a 2009
Federal Budget initiative, now incorporates a number of previously
separate programs, including the Outer Metropolitan Specialist
Trainee Program (OMSTP) and the up-skilling program aimed at
overseas trained specialists working toward Fellowship of a specialist
medical college. Application processes for proposed positions to
begin from 2011 are intended to commence soon and the College
will assist in publicising the details as soon as they become known.
Like obstetrics, leading and

managing is an intensely human
activity not on the same life and
death scale, of course but still on
a level that affects individuals in an
organisation on a daily basis and
which must be practised with an
eye for the affective components
involved.
As well as the consolidation of a number of programs in relation
to specialist training, the 2009 Federal Budget also saw the
consolidation of a number of programs relating to continuing
professional development for specialists, including the Support
Scheme for Rural Specialists (SSRS). While the initial intention was
to amalgamate the SSRS program with other programs, recent
communication has indicated an extension of the SSRS program
until the middle of 2010, with details of the exact nature of the
future funding arrangements (therefore, a separate, stand-alone
program or amalgamated with others) not clear at this time.
By the time this edition of O&G Magazine is being read, Council
will have further considered the matter of College governance
arrangements, a matter that, increasingly, those who are involved
with the governance of the College realise is in some need of
attention. A review of the overall College activities from a risk
management perspective has been undertaken and completed,
providing an up-to-date risk profile for the organisation. Members
can be assured that identifying and mitigating potential risks to
the College is something that all involved in College governance
are very much aware of and looking to address in an increasingly
systematic manner. That said, however, we operate a somewhat
distributed organisation in dynamic times and this, in and of itself,
presents challenges for us.
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After lApAroscopic surgery for Adhesiolysis: A double-blind, rAndomized, controlled study fertility And sterility, volume 88, issue 5, november 2007, pAges
1413-1426 2. menzies d. pAscAl mh, wAlz mK et Al. use of icodextrin 4% solution in the prevention of Adhesion formAtion following generAl surgery: experience
from the multicentre Ariel registry. Ann r coll surg engl 2006. in press.
The College
As anticipated, the appointment of a Director of Education and
Training has been a valuable strategic move for the College. It has
enabled the progression of activities that will assist us in ensuring we
are progressing the core business, for which the organisation exists,
in a manner that is expected from all stakeholders, both internal
and external. Currently, there is much activity in relation to what is
essentially the core business of the College, with much more to be
debated and implemented over time. As a snapshot, the following
are of note:
A review of the content of the RANZCOG Curriculum (therefore
the FRANZCOG training program);
A review and revision of the Flexible Learning Program (FLP),
construction of online modules to support the research project
requirement of the FRANZCOG training program and online
training supervision modules to assist those undertaking the
important role of supervising trainees;
The trial of a revised continuing professional development (CPD)
framework aligned to the RANZCOG Curriculum;
The development of new curricula for the DRANZCOG and
the DRANZCOG Advanced under the auspices of the Conjoint
Committee for the Diploma of Obstetrics and Gynaecology
(CCDOG), the body now responsible for the oversight of the
Diploma qualifications; and
Continuing review of the assessment processes for overseas
trained specialists to ensure they are as robust and fit for purpose
as possible.
Along with the President, I recently attended the 19th FIGO
Congress in Cape Town, South Africa. The meeting was a wellorganised event with a large number of delegates. My attendance
enabled a better understanding of the work of FIGO and some of
its member organisations in the context of possible partnerships
and initiatives in which RANZCOG could become involved. This
was particularly so in relation to initiatives surrounding the United
Nations Millennium Development Goal Five (MDG 5)1 that aims to
improve maternal health, with two articulated targets:
1. Reduce by three quarters the maternal mortality ratio.
2. Achieve universal access to reproductive health.
According to the United Nations website, the following points are
made in regard to Target One:
The high risk of dying in pregnancy or childbirth continues
unabated in sub-Saharan Africa and Southern Asia;
Little progress has been made in saving mothers lives; and
Skilled health workers at delivery are key to improving outcomes.
In regard to Target Two:
Antenatal care is on the rise everywhere;
Adolescent fertility is declining slowly; and
An unmet need for family planning undermines achievement of
several other goals.
The above notwithstanding, there are localised examples of where
good progress has been made in regard to MDG 5. However, there
is clearly more that needs to be done, in some cases in regions
and countries that RANZCOG is very aware of and familiar with.
There are opportunities for the College, through the Asia Pacific
Committee and in conjunction with other organisations, to play a
role in furthering the achievement of MDG 5 in those places.
The College has had conversations with the Australian Parliamentary
Secretary for International Development Assistance, the Hon Bob
McMullan, in an effort to make further links with AusAID and other
potential partners, to facilitate capacity-building that will enable
us to make positive contributions in this area. In conjunction with
the Pacific Society for Reproductive Health (PSRH), the College
also made a written and verbal submission in September to a
hearing on maternal health in the Pacific, conducted by the New
Zealand Parliamentarians Group on Population and Development

(NZPPD). Attendance at the hearing was useful in terms of enabling
an understanding of the contributions being made by a range of
groups, who are currently undertaking activities in regard to this
aspect of College work. The knowledge gained will also assist
in the formulation of strategies and initiatives for the Asia Pacific
Committee to consider.
The Colleges Annual Accreditation report to the Australian Medical
Council (AMC) was submitted in September and my thanks go to all
involved in its compilation. As well as indicating to an independent
external body the activity that has been undertaken by the College
in relation to the areas covered by the standards in the time since
the previous report was submitted, the reports enable the College
to assess its progress in what are essentially its core business areas;
that is, education and training (including assessment) and CPD.
Of interest is that there are still recommendations from the original
accreditation report of 2003 that are pertinent to the evolution of
the College today and on which we are still asked to comment. It is
important that we use the accreditation process and the feedback
to our annual reports from the AMC to guide us in a way that is
strategic, as well as addressing some specific aspects of the training
and CPD programs.
It is my intention, in conjunction with the Director of Education
and Training and the chairs of relevant College committees, to
undertake a systematic audit of the accreditation standards to
ensure that the College has up-to-date policies and procedures in
place in relation to the major of aspects of core business covered
by the standards. This is in addition to any strategic initiatives that
may be undertaken as part of the evolution of College activities in
relation to areas covered by the standards.
Of note, also from the AMC, is the production of the document
Good Medical Practice: A Code of Conduct for Doctors in
Australia. The code was developed in the context of the move
to a national system of registration for medical practitioners in
2010 under NRAS and included wide consultation with a range
of stakeholders, including the specialist colleges. The code may
be accessed at: http://goodmedicalpractice.org.au/ . Councillors
may also be interested in the document recently published by
FIGO, Ethical Issues in Obstetrics and Gynecology by the FIGO
Committee for the Study of Ethical Aspects of Human Reproduction
and Womens Health (www.figo.org/about/guidelines).
The last weekend of October saw the holding of MedEd09, a
conference covering all stages of the so-called continuum of
medical education in Australia. Convened under the auspices
of Medical Deans Australia and New Zealand (MDANZ), the
conference was sponsored by MDANZ, the Australian Government
Department of Health and Ageing, the Australian Medical Council
(AMC), the Committee of Presidents of Medical Colleges (CPMC)
and the Confederation of Postgraduate Medical Education Councils
(CPMEC). The conference theme was Investing in Our Medical
Workforce. I was fortunate to be involved with the organisation as
a nominated representative of the CPMC, while RANZCOG Fellow,
Professor Judy Searle, was also part of the organising group. The
Director of Education and Training attended the conference, former
RANZCOG President, Dr Ken Clark, spoke on the program about
the New Zealand perspective of health workforce and education,
and Dr Jolyon Ford spoke about Recognition of Prior Learning as
part of a session titled Achieving Vertical Integration.
The conference was held at a time where many initiatives relating to
health workforce and training are being undertaken, some at more
advanced stages than others. The international keynote speaker
for the conference was Sir John Tooke, Dean, Peninsula College of
Medicine and Dentistry, Universities of Exeter and Plymouth, UK.
The College
Professor Tooke chaired the Independent Inquiry into Modernising
Medical Careers, following the problems associated with the
Medical Training Application Service (MTAS) process, with the final
report of the inquiry published in January 2008.
Based on activities at the conference, it is the intention to produce
recommendations relating to health workforce and training for
consideration by stakeholders. Draft recommendations produced
during the conference related to areas such as Commonwealth and
State coordination of medical education; the role of competencybased training in medical education; the role of the generalist in the
Australian health workforce; the importance of adequate resourcing
of training institutions; the acknowledgement of the role of
supervision in job descriptions; and the relationship between service
delivery and training.
EPI-NO reduces the risk

of perineal tearing and
episiotomy
Finally, as the end of the year approaches, I would like to thank

all involved in progressing the work of the College during 2009.
Again, much has been achieved and still the list of what remains
shows little sign of waning. Not for the first time, I have referred
above to the exciting, yet turbulent, time and environment in which
the specialist colleges are operating. It is incumbent on us all who
are involved in the stewardship of RANZCOG to ensure that we
strive to act in the true tradition of such stewardship and leave the
organisation in better health than when we encountered it, so that
the next generation may look with appreciation on what has been
achieved during our period of involvement.
I wish all College members, staff and their families a happy and
satisfying holiday season. I look forward to the challenges that
2010 will bring us as we once again take on the task of stewarding
RANZCOG for the future.
Reference
1. www.un.org/millenniumgoals/maternal.shtml#mdgs .
Prepares the Perineum

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Australian Medical Couches

10 O&G Magazine
69 Hardiman Street
Kensington Vic 3031 Australia
Everyones a critic
It is from the womb of art that criticism was born.
Charles Baudelaire
think that the greatest single similarity

between the artist and the obstetrician
is that both endure the attentions of
critics. Obstetric morbidity and mortality
meetings at my hospital certainly smoke
out the critics and I have no doubt this
is the same everywhere. Criticism, be it
artistic or clinical, is an essential part of
creative activity. Denis Dutton, a vocal
A/Prof Steve
expatriate American now living in New
Robson
Zealand, specifically lists criticism
FRANZCOG
the fact that we make a point of
judging and interpreting art as one
of the essential signatures of artistic
endeavour. Fortunately, criticism is down his list. The attribute that
heads Duttons list is virtuosity and the way that artistic skills are
recognised and admired.
It is difficult not to admire displays of virtuosity on the birth suite.
Who amongst us hasnt had our breath taken away, at some
stage in our careers, while watching a vaginal breech delivery or
perhaps a deft rotational forceps birth, or the skilful management
of a second twin. For a long time, I have thought of this in terms
of accoucheur as artist. By the same token, I have also seen (and
unfortunately been a part of) some artistic disasters that rightly
deserved a shellacking from the critics. Indeed, labour is not a
blank canvas. When things go badly, as they sometimes do, the
obstetrician is at best deeply immersed in a grand restoration
project.
What about science? If art defies definition, so too does science.
The word science derives from the Latin for knowledge, and in its
strictest sense refers to the method of increasing knowledge through
systematic research. The problem for us is that, at any given time,

most of what we take to be scientific truth is actually wrong. Take a
glance through one of the older textbooks of obstetrics and you will
get a sense of what I mean. John Ioannidis, from Tufts University in
the United States, has studied published research papers in medical
literature and concludes that most are subsequently proven to be
incorrect.1 This is something that needs to sink in for all of us: much
of the published scientific data that influences our management of
patients today will ultimately prove to be wrong.
I have no doubt that in years to come we will all look back at our
current practices and laugh. Some people look at my practice
and laugh now. Perhaps this is the essential point of difference
between science and art, then. I sometimes wander around the
National Gallery here in Canberra and struggle to embrace the
post-modern, yet I look fondly on the more classical canvases and
sculptures, probably because they seem more realistic. This is of
course a load of rubbish. Life isnt, and never has been, remotely
like the scenes of the classical artists. We just wish it was.
In this issue of O&G Magazine, we have tried to draw together the
disparate views of obstetric scientists and artists. Some of us have
pretensions to both and that is not a bad thing. If you are expecting
an answer to the question as to whether obstetrics is art or science,
you will be disappointed. In every other way, we hope you find this
issue as stimulating as we did putting it together for you. As always,
we thank our contributors for the time and thought they have given
to you, the reader.
1.
Ioannidis JPA. Why most published research findings are false.

PLoS Med 2005; 2(8): e124.
Are you registered on the RANZCOG website under our

locate an obstetrician/gynaecologist link?
Can your colleagues locate you for referral purposes?
On the College website, two Register of Fellows are published: a publicly accessible register of active Fellows in
Australia and New Zealand and a restricted access register of all College members.
The PUBLICLY ACCESSIBLE Register of Active Fellows lists your work address, phone number and brief practice details
(for example, private and/or public obstetrics and gynaecology or area of subspecialty).
The RESTRICTED ACCESS Membership Register lists the work contact details of members of the College who wish to be
included and is accessible only by members of the College who have a website user name and password.
If you would like your work contact details to be included on either or both of the registers and/or would like to update
your details already listed on the website, please contact:
Tracey Wheeler
(t) +61 3 9417 1699
(e) reception@ranzcog.edu.au

Clearly, obstetrics is both a science and an art, but the balance has altered through
the centuries of recent history and it is interesting to reflect on the changes.
Where better to start a discussion
about the nature of obstetrics than the
Hippocratic Oath, particularly the words
of the modern version by Louis Lasagna
in 1964: I will remember that there is art
to medicine as well as science and that
warmth, sympathy and understanding
may outweigh the surgeons knife or the
chemists drug.
Dr Tony Baird
Until about 150 years ago, warmth

and compassion were all that could
be offered to women, but prior to that
time, observations were recorded, gathering information about
aspects of pregnancy. Quite a lot was known about normal and
abnormal obstetrics and remedies were being developed. For many
centuries, medical men attended women in their confinements
and women gave support. Some historical points are surprising.
The obstetric forceps were probably invented around the year 1600
by Peter Chamberlen in England. The slack cervix in premature
labour was noted soon after; the principles of the Ventouse were
first established in 1706; and the distinction between accidental
antepartum haemorrhage (abruption) and inevitable haemorrhage
from placenta praevia was recognised in 1775 in Norwich.
FRANZCOG
Caesarean section is almost certainly one of the oldest operations

in surgery. It was performed prior to the year 1500 as a postmortem
procedure to try to save the child. Some women survived during the
17th century when caesarean section was done, usually with a razor,
and there are records of 131 caesarean sections being done in
England between 1737 and 1878; 23 women survived. In the year
1870, the death rate was in the region of 80 per cent because the
uterus was not sutured and the best results after that occurred when
the caesarean section was followed by a sub-total hysterectomy.
The transverse lower segment incision was first described in 1882 in
Berlin. There is doubt about the word caesarean. The most plausible
explanation is that it was a rule of the early emperors, the caesars,
who succeeded the kings of Rome, one of whom, Numa Pompilius,
in 715 BC made a law that forbade the burial of a pregnant woman
until the child had been removed from the abdomen in order
that the child and mother might be buried separately. Goodness
knows what those poor women would think about todays festive
occasions, birth booked at a convenient time bypassing labour,
painless under a regional block in surroundings like a hotel.
The effect of oxytocinon on a womans uterus was described in
1808, but it was another 130 years before a preparation was
produced that would effectively treat haemorrhage. Haemorrhage,
sepsis, pulmonary embolism, criminal abortions and eclampsia
were the main reasons for maternal mortality, which was recorded
as 4.8 per 1000 births in the United Kingdom at the beginning of
the 20th century. A new era in obstetrics began in the 1850s when
Sir James Young Simpson, professor of midwifery in Edinburgh, used
chloroform to relieve the pain of childbirth. This was followed by
the work of people like Joseph Lister, Ignaz Semmelweis and Louis
Pasteur, who were responsible for the great reduction in deaths due
to infection.
12 O&G Magazine
It was another of the Peter Chamberlens (there were three of them

around the same time) who was the first to suggest the creation
of an incorporation of midwives 400 years ago. Midwives were
men and women at the time and precursors of obstetricians, the
words meaning watch and wait or stand before and the titles were
interchangeable until recently.
Formal antenatal care in the western world had its beginnings in
1901, including advice on diet, social conditions and physical
and psychological wellbeing, as well as developing into a branch
of therapeutic and preventative medicine throughout the world.
Improvement in the general health of women led to a century
of major advances in the understanding of the physiology and
pathology of procreation, with dramatic reductions in maternal and
perinatal mortality in developed countries.
Improvement in general health, housing and water was
complemented by oxytocics, antibiotics, safer anaesthesia, abortion,
blood transfusion and lower segment caesarean section. Local
contributions include putting science into the understanding of
rhesus disease and the use of corticosteroids antenatally where
premature labour threatens. Sedatives, anti-hypertensives, iron
supplements, insulin and anti-convulsants are just a few of the
agents that have reduced mortality and morbidity. The publication in
1989 of the first guide to effective care in pregnancy and childbirth
followed a review of over 60 key journals from the 1950 issues
onwards leading to the concept of evidence-based medicine.
The science of pharmacology has had a profound effect on
obstetrics, including the oral contraceptive, which arrived in this part
of the world in the early 1960s, raising great expectations, although
the human limitations of science are apparent as fewer than 50 per
cent of pregnancies are actually planned.
Ultrasound has meant an astonishing amount of information is
available to pregnant women and the ultrasound scan sometimes
seems to have supplanted the clinical skills of taking a history by
talking to women and then doing a physical examination. In 1972
in London, I saw the early, grainy images of pregnancy ultrasound
that Professor Ian Donald had been perfecting during the previous
decade, initially measurements in one dimension of the biparietal
diameter and in the following decade, the perfection of the twodimensional B scan. Since then, there has been an enormous
technological leap to four-dimensional pictures for a personal disc
of the fetus and measurement of liquor volumes to amniotic fluid to
two decimal places. All of the information that is available comes
with some that is unwanted.
How much further can science go? We need to know more about
the onset of labour and there is still a lot that we do not know.
However, the application of ultrasound begs the question of what
to do with all of the information that we have at our disposal now
and how best to apply the remedies, which comes back to the art of
obstetrics. It is time to alter the balance again.
Uncertainty is a constant feature of all medicine, particularly
obstetrics. Pregnancy is a natural event of course, as our midwifery
colleagues remind us when we are too interventional. Sadly,

nature can be cruel. The unexpected occurs with perinatal loss
and life-threatening conditions for women so, still, there are many
dilemmas and enigmas. Childbirth has become a natural event for
fewer women despite our best efforts and the number of standard
primigravidae in the Robson classification is declining.
We know a lot about diabetes mellitus for which treatment is both
available and effective, but we seem powerless to halt the tsunami
of obesity. Gluttony and sloth are all around us, adding complexity
and morbidity to the pregnancies of women in increasing numbers.
Smaller families add to the pressure for perfect babies, reducing
tolerance to risks to an unreasonable extent sometimes; the gap
between expectation and reality seems to be widening. There is the
whole new industry of support and complaints, requiring honesty
and compassion, which are part of the art of counselling in times
of tragedy. Other recent developments include the management
of health services, which in times of budgetary restraint is an art,
sometimes resembling a circus. However, doctors have an ethical
duty to use limited resources wisely, which has the potential to
give rise to conflict. Epidemiology comes between science and art,
helping us to understand information and put it into practice. Also,
the development of medical colleges during the past century has
facilitated the spread of information, research has been supported
by governments and the development of a subspecialty of maternalfetal medicine has been beneficial.
Clearly, advances in perinatal care have been amazing. They have
enabled us to intervene earlier and to reduce the perinatal mortality
to single figures. The perinatal mortality rate was first introduced
in 1930; it was 63 per 1000 births in that year in England and
Wales, mainly from prematurity, asphyxia, congenital abnormalities,
birth injuries and infection. Despite achievements in the care of
the newborn, there will always be some perinatal loss, mostly
unavoidable and unexpected. Nature produces oddities in offspring
which Charles Darwin, in The Origin of the Species, published 150
years ago, refers to as monstrosities, a word which illustrates the
change in attitude and language since then.
Information about complaints reveals that female obstetricians
are less likely to be complained about than men. There are many
factors involved, but undoubtedly the art of communication,
especially listening and choice of words, is the attribute that is
essential to good care, as well as reducing the likelihood of
complaint, litigation and disciplinary action. Unfortunately, there
has been a rise in defensive medicine and too much intervention
in the forlorn hope of eliminating all risk. Additional skills are
needed to communicate well with women who, generally, are not
sick when they are pregnant and to work collaboratively with other
professional people, particularly midwives, who contribute so much
to womens health.
Basic sciences are essential for knowledge of obstetrics. Scientific
achievements have contributed to safer childbirth, but the words
of Montaigne, who lived from 1533 to 1592, are pertinent: The
practice of the physician is an art, a craft, a skill, a vocation for
which examination papers never have been and never can be set.
Obstetrics has inspired a lot of art paintings, music, poetry and
literature glorifying pregnant women and newborn babies and
commemorating the losses. It represents the best and worst of life,
still fundamentally a human activity, a special time for women and
their families and a wonderful specialty for doctors. Ultimately, it
involves the art of communication, the interpretation of scientific
facts for the benefit of individual women and mindfulness at all
times.
SPECIALIST OBSTETRICIAN
AND GYNAECOLOGIST
Canberra Hospital
Department of Obstetrics
and Gynaecology
The Department of Obstetrics and Gynaecology at Canberra
Hospital provides tertiary level obstetrics and gynaecological
services to the ACT and surrounding regions. Canberra Hospital
has more than 2500 births per year and is a principal referral
centre for high risk pregnancies for the region.
It is the only tertiary care perinatal unit between Sydney and
Melbourne and has a busy Fetal Medicine Unit. Canberra Hospitals
Centre for Newborn Care has 650 admissions per year with eight
intensive care beds, soon to be increased to 10.
The Department provides gynaecological services to the same
region and with support for gynaecological oncology from
Royal Womens Hospital Randwick. The department has a well
supported RANZCOG training programme with a Senior Registrar
and 9 registrars including those rotated to other metropolitan
and rural rotations.
There is a very active junior doctor programme which is
producing excellent quality trainees interested in continuing
in Obstetrics and Gynaecology. Involvement in departmental
teaching and research is recommended and highly encouraged
and supported. There is a strong commitment to quality and
audit.
The Canberra Hospital is a teaching hospital of the Australian
National University (ANU) Medical School and an academic title
at a level commensurate with qualifications and experience
will be available to the successful applicant. ANU is one of the
worlds foremost research universities. Distinguished by its
relentless pursuit of excellence, ANU attracts leading academics
and outstanding students from Australia and around the world.
The ANU campus is only a short drive from Canberra Hospital
and offers a great range of research opportunities.
Plans are underway for expansion and refurbishment of the
building with $90 million committed to the new Women and
Childrens Hospital Centre of Excellence at Canberra Hospital.
Qualifications/Other requirements: Registration as a
medical specialist practitioner in the ACT. FRANZCOG or an
equivalent higher specialist qualification accepted by the
Royal Australian and New Zealand College of Obstetricians
and Gynaecologists. Higher Medical Qualifications means
medical qualifications obtained by an officer subsequent to
graduation in medicine which are required by the National
Specialist Advisory Committee or such other postgraduate
qualification which the ACT Health Service may from time to
time choose to recognize for this purpose.
Contact Officer
Dr Anne Sneddon Ph: (02) 6244 3538
Please note: No recruitment agency
applicants for this
position
Vol 11
No 4 Summer 2009
13
Reflections on my initiation
into the secret world of
complex vaginal birth
Dr Keith Hollebone
FRANZCOG
At the beginning of my career in obstetrics, I had the distinct impression,

perhaps hope, that I was joining a secret society. In those days (I wont
say exactly when), obstetricians were virtually all suited gentlemen,
notwithstanding the occasional woman, who inhabited a world where day
and night didnt seem to matter.
Their demeanour was flamboyant and very self-assured. In that era,

fewer than one baby in ten was delivered by caesarean section.
Such a low rate of caesarean delivery seems daring and most
curious these days, but in years gone by, caesarean section was
regarded as a highly dangerous operation only to be performed as
a last resort. The operating theatre was referred to disparagingly
as the cowards corner. The tools for monitoring pregnancy were
basic ultrasound was unheard of and x-ray was the only way to
visualise the baby and the placenta. Large bottles of urine, in which
urinary oestriols were assayed, represented the best we could do to
assess fetal progress. The cardiotocograph was in its infancy and
our knowledge of the science of pregnancy seems almost primitive
now. The obstetricians of yore therefore relied more on their
experience, or gut feelings, to lead decision-making.
...in years gone by, caesarean

section was regarded as a highly
dangerous operation only to be
performed as a last resort.
In the labour ward they were artists. Their ability to use Kjellands
forceps to finesse breech deliveries, to perform manual rotations
and to successfully deliver twins vaginally was superb. The epidural
block was not widely used and many such complex vaginal births
were conducted under either pudendal nerve block, or sometimes
general anaesthesia. Mistakes happened, but the general consensus
in the population was that the doctor had tried his (or her) best and
one didnt question their actions. They were treated as doyens or
gods. Ill refrain from referring to this as the golden era, though.
As in many other areas of endeavour in our society at the time,
change was afoot. The shadow of science was creeping into
the labour and antenatal wards. The fetus was subject to closer
monitoring, both by the emerging technologies of ultrasound
and with the CTG machine. Knowledge of the complications of
pregnancy improved. Anything seemed possible.
At the same time, epidural analgesia had been introduced
and became widely available. This was one of the factors that
made caesarean section a much safer procedure. Anaesthetics
administered acutely in labour ward became a thing of the past.
People at all levels, both professional and in the lay population,
began to question the doctors actions and to make demands about
14 O&G Magazine
their care. Mistakes still occurred, but now people tried to find a
resolution through the law. The result of this was the escalation in
indemnity insurance charges, a trend that has continued to this day.
Inevitably, closer monitoring of obstetric outcomes was undertaken
and complex obstetric procedures came under scrutiny.
Trainees of the time saw that it was no longer sufficient to try ones
best. Results became everything. Perhaps it should surprise nobody
that professional and lay perceptions developed that if a caesarean
section was performed, everything that could be done was done, at
least in the eyes of the law. As a predictable result, obstetric practice
saw a reduction in the number of clinical situations where it seemed
acceptable to perform the more challenging procedures associated
with complex vaginal birth. As trainees were exposed to fewer and
fewer breech deliveries, instrumental rotations and twin deliveries,
training opportunities were lost and thus began a gradual deskilling of the obstetric medical workforce.
We all had the feeling, prompted by the publication of various
studies attesting to the fact, that more traditional obstetric practice
might in some way be significantly increasing risk to both the patient
and the baby. With the passage of time, some of these articles
have been shown to be flawed, but the damage was already done.
Vaginal breech delivery, vaginal twin delivery and Kjellands forceps
delivery had come to be regarded as dark and dangerous practices,
akin to the goings on in a medieval torture chamber.
Are these procedures actually dangerous? It is difficult to make valid
comparisons with outcomes of 20 or more years ago. With the aid
of modern techniques such as ultrasound, we are well-equipped
to exclude those patients at higher risk of problems in labour.
The judicious use of epidural and spinal analgesia has made the
possibility of having good pain relief in labour almost universal
in Australian hospitals. Monitoring of patients in labour with a
cardiotocograph and a better understanding of what fetal heart
traces are actually telling us, along with our ability to take scalp
blood samples to exclude or diagnose acidosis, has meant that
appropriate action can be taken in a timely manner.
Patients are, naturally, at the centre of this. Many seek midwife-led
care and midwives espouse that normal vaginal birth is the safest
way to go, while obstetricians are seen to resort to caesarean
section much too frequently. My impression is that the general
feeling in our community is that caesarean section is a relatively
safe option compared with complex vaginal birth. However,
complications of caesarean section, although rare, can be extremely
severe if they occur, a fact that is not always stressed to the patient.

IVF and delayed conception has increased the level of fear and
anxiety in patients concerning the method of delivery. Obstetricians
are, in cases such as these, more prone to intervene early with
caesarean section when there have been major problems in falling
pregnant and arriving at delivery time. Pregnancies that have
resulted after long and arduous fertility treatments are often labelled
as precious, although I suspect that all babies are precious to their
parents.
As trainees were exposed to

fewer and fewer breech deliveries,
instrumental rotations and twin
deliveries, training opportunities
were lost and thus began a gradual
de-skilling of the obstetric medical
workforce.
A complex vaginal delivery carries with it certain risks to the
mother, particularly in terms of trauma to the pelvic floor, but this
has been shown to occur even without vaginal delivery. The baby
is not without risk during caesarean section, with the possibility of
damage to the baby during the delivery and increased possibility
of respiratory difficulty in births before 39 weeks. The psychological
trauma of caesarean section has been described, but is often

hidden from obstetricians.
The obstetrician is left with the caesarean section as the only
method of delivery that remains theirs, unless they are trained to the
arts of complex vaginal delivery.
From a personal perspective, as an obstetrician, I find caesarean
section at best boring, at worst terrifying and am sad that it
might become the only tool in our armoury. There is no doubt
that successfully performing complex vaginal deliveries can be
extremely rewarding to the obstetrician and it allows the patient
to have a sense of satisfaction in its achievement. Today we have
unprecedented assistance from imaging and monitoring of the fetus
to help us assess the likelihood of success in delivery, as well as the
wellbeing of the fetus during the attempt. History has taught us that
these deliveries can be safe, but it is up to our senior colleagues to
teach and train juniors in the tips and techniques that allow them to
be performed safely.
The future lies in obstetricians being prepared to put aside their
fears and to be prudent in selecting the right situations in which
to attempt complex vaginal delivery. With the help of modern
investigative techniques, it is now possible to select, with reasonable
accuracy, the low-risk patients who are suitable for this form of
delivery. No one is expecting a return to the old days, but an
obstetrician is still an obstetrician and should not become an
obligate caesarean sectionist.
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Complex vaginal deliveries

Why are we still doing them?
Dr Martin Sowter
FRANZCOG
Before beginning, I should perhaps quote from James Young Simpson, the
late Professor of Midwifery at Edinburgh University and inventor of both the
Simpsons air tractor, the original forerunner of the modern vacuum extractor, and
Simpsons forceps: Obstetrics is not an exact science, and in our penury of truth
we ought to be accurate in our statements, generous in our doubts, and tolerant
in our convictions.
His near simultaneous development of both a vacuum extractor and

a pair of forceps suggests that uncertainty over how best to affect an
instrumental delivery is far from new.
My initial thoughts when asked to discuss why we are no longer
doing complex vaginal deliveries were that I wasnt aware that we
were no longer doing them. The evidence suggests that we probably
are, though possibly in slightly smaller numbers, in theatre rather
than in the delivery room and using different instruments.
For the purpose of this discussion, I will define complex vaginal
delivery as an instrumental delivery where the fetal head is not in an
occipito-anterior position.
The incidence of malposition has

not changed and, like it or not, the
great majority of complex vaginal
deliveries are going to be done by
Ventouse or caesarean section in the
future.
Being well into the middle third of my consultant career, I would
have been one of the last generation of juniors to be let loose on
delivery unit with a pair of Kjellands forceps and perhaps some
indirect supervision from a senior registrar writing up their MD thesis
far away in the doctors mess. Even at that time, their use was in
steady decline. Recent Australian data confirms that within a few
years almost no practitioners will be confident in their use.
In a survey of 303 obstetric trainees in Australia in 20071, the
median number of Kjellands deliveries performed by trainees in
Year Four was only two, with only ten per cent of final year trainees
having performed ten or more. More importantly, 94 per cent of
final year trainees stated the intention was that they would not be
performing Kjellands forceps as a specialist. Earlier Australian
studies2 had shown a similar but less extreme picture and this most
recent survey has confirmed a rapid decline in trainees and new
specialists experience with this instrument.
However, the incidence of malposition has not changed and, like it
or not, the great majority of complex vaginal deliveries are going to
be done by Ventouse or caesarean section in the future.
Is this a concern? Systematic reviews report that the risk of maternal
trauma is lower with a Ventouse than a forceps delivery. They
also report that, when used for a trial of labour in theatre (for any
position), there is a greater chance of conversion to caesarean

section.3 Women transferred to theatre at full dilatation for delivery
have a higher risk of haemorrhage and prolonged hospital stay
if delivered by caesarean section than if delivered by a successful
instrumental delivery while in theatre.4 The unanswered question
is whether the apparently higher morbidity of rotational forceps
is balanced by the lower success rate of rotational Ventouse and
higher morbidity of caesarean section for those failed instrumental
deliveries. Confounders are that cohort studies report varying rates
of morbidity with Kjellands forceps. They also report lower rates of
conversion to caesarean section, as well as a lower morbidity if a
caesarean section is required, with increasing operator experience.
Does it all depend on how good the obstetrician is?
The increased risk of conversion to caesarean section that appears
to be associated with the use of the Ventouse (or at least when used
by a wide range of operators) for a rotational delivery is probably
an important factor in the gradual movement of the complex
vaginal delivery out of the delivery room into the operating theatre.
One recent UK cohort study suggested that four per cent of women
are now delivered in theatre by instrumental delivery or a caesarean
section at full dilatation.4 Performing a high proportion of rotational
deliveries in theatre would be a move that I would fully support.
In our overstretched and poorly staffed delivery units, a failed
rotational Ventouse in the delivery room can be the beginning of
a stressful journey to the operating theatre of wildly unpredictable
duration. Initiating the rotational delivery in theatre might
slightly increase the conversion to caesarean rate and frequently
annoy theatre staff, but it will dramatically shorten the time from
abandoning the procedure to safely delivering the baby.
A successful rotational delivery does result in a much higher chance
of a vaginal delivery next time simply because the proportion
of women who even attempt a vaginal birth after caesarean
is relatively low. That said, one should not underestimate the
importance of post-traumatic stress associated with instrumental
delivery. A similar number of women report such symptoms after an
instrumental delivery in theatre as women who experience a section
at full dilation.5 Post-delivery follow-up is often far more elastic after
an instrumental delivery, but there is evidence to support providing
women who have had a successful trial in theatre an opportunity for
debrief and as much psychological support as those who required a
caesarean delivery.
So will we still be doing complex vaginal deliveries in the future?
Yes, of course. For the future, we should probably just admit that
the Kjellands forceps have been effectively consigned to history
and concentrate on making rotational delivery using the Ventouse
more effective and safer. This sentiment might inflame experienced
Kjellands users. However, like those 94 per cent of current trainees,
I felt at the end of my training that I had done more than enough

Kjellands (and perhaps more importantly, seen more than enough
effected with varying degrees of expertise by colleagues) to feel that
I was better off concentrating my skills on the use of the occipitoposterior cup (OP cup).
There is ample evidence that many operators are poorly trained
in vacuum extraction and, given that the success of this procedure
relies entirely on correct cup placement and traction, we need to
ensure that training in its use is both structured and comprehensive.
We also need to accept that many of these deliveries will now be
done in theatre and adjust both our labour ward protocols and
staffing to facilitate this. Finally, we also need to recognise that there
may be just as much psychological morbidity associated with the
successful complex vaginal delivery as an unsuccessful one and
ensure that we support women at the time of their delivery and postnatally in order to minimise this.
References
1.
2.
3.
4.
5.
Chinnock M, Robson S. An anonymous survey of registrar training in

the use of Kjellands forceps in Australia. Australian and New Zealand
Journal of Obstetrics and Gynaecology 2009; 49: 515-516.
Robson S, Pridmore B. Have Kielland forceps reached their use
by date. Australian and New Zealand Journal of Obstetrics and
Gynaecology 2000;40:226-227.
Murphy D. Maternal and neonatal morbidity associated with operative
delivery in the second stage of labour. Recent Advances in Obstetrics
and Gynaecology 2003; 22: 85-94.
Murphy D, Liebling R, Verity L, Swingler R, Patel R. Cohort study of
the early maternal and neonatal morbidity associated with operative
delivery in the second stage of labour. Lancet 2001; 358:1203-1207.
Bahl R, Strachan B, Murphy D. Outcome for subsequent pregnancy
three years after previous operative delivery in the second stage of
labour. BMJ 2004; 328: 311-314.
New O&G Magazine index

O&G Magazine will publish an annual
index in every December edition from 2009
onwards, which will include both author and
subject indexes.
This year, we have published a special
cumulative index to cover volumes 7 to 11.
You can find it on page 80 of this issue.
O&G Magazine is now fully indexed from
volume one through to the present. You can
also find the indexes online at: www.ranzcog.
edu.au/publications/oandg.shtml .
We hope our readers find these new
indexes useful!
ASUM Annual Obstetric Symposium 2010

in conjunction with ASUM Multidisciplinary 2010 Ultrasound Workshop
visit www.asummdw.com.au for preliminary program, faculty and fees
Learn from the leaders...

O&G n Musculoskeletal n Cardiac n Vascular n Abdominal n Paediatric n Small Parts
Multidisciplinary Workshop 1920 March
DMU Preparation Courses 1721 March
DDU Technical Seminar 1718 March
Hilton Hotel
Brisbane Qld Australia
Australasian Society for Ultrasound in Medicine
PO Box 943 Crows Nest NSW 1585 Sydney Australia

ASUM email info@asummdw.com.au n tel +61 2 9438 2078 n fax +61 2 9438 3686
18 O&G Magazine
Forceps delivery
Science wears its art on its sleeve
A/Prof Steve Robson
FRANZCOG
Prof Caroline de Costa

FRANZCOG
Few of us think about it, but the obstetric forceps have been
calculated to have saved more lives than any other instrument.
Thats quite a rap for two pieces of interlocking surgical steel made
to a design that hasnt really changed in our lifetimes. Yet with
more than 130 million births around the world each year and with
the perinatal death rate for unassisted vaginal birth as high as one
in ten in some developing countries, such a revelation should not
surprise us at all.
In countries where accurate records are kept, the rate of
instrumental delivery is about ten per cent.1 For Australian women,
the proportion of all births that were instrumental vaginal births
fell only slightly from 11.3 per cent in 1995 to 10.7 per cent a
decade later.2,3 However, over that time period, the proportion
of instrumental births conducted with forceps more than halved,
from 7.8 per cent to 3.5 per cent. Over that same decade, the
rate of caesarean birth doubled. Why the sudden drop in forceps
deliveries?
The obstetric forceps have been

calculated to have saved more lives
than any other instrument.
The RANZCOG statement regarding instrumental vaginal delivery
(C-Obs 16, available on the College website) makes the following
observation about choice of instruments: Each instrument has
a different profile of complications. Delivery is more likely to be
achieved with forceps than vacuum and will occur over a shorter
time interval. The clinician should select the instrument based on his
or her clinical experience and the clinical circumstances.
Similarly, the extant RCOG Green-top Guideline on instrumental
vaginal delivery states: The operator should choose the instrument
most appropriate to the clinical circumstances and their level of skill.
Forceps and vacuum extraction are associated with different benefits
and risks.
What has happened over a decade that forceps are being
abandoned? It seems unlikely that the clinical circumstances
referred to by the RCOG have changed for such a large number of
women. Although the rate of caesarean birth has rapidly increased,
those abdominal deliveries do not seem to have been performed
at the expense of operative vaginal delivery, since the rate of
instrumental birth has remained essentially static. As long ago as
1972, prominent London obstetrician Peter Huntingford wrote:
There are now only two routes of birth: easy vaginal delivery and
caesarean section. If one in ten births still require instrumental
assistance, what is going on?
The obstetric forceps is attributed to the Chamberlen family and

although many variations have appeared over the years, the basic
principles of design are unchanged from the original Chamberlen
prototype. The Chamberlens were French Huguenots who fled
the 16th century pogroms of Catholic France for England, where
Dr William Chamberlen established himself in 1569. William had
five children, of whom two, both called Peter, were also doctors.
Peter the Younger also had a son called (yes!) Peter (Dr Peter), who
in turn had a son called Hugh who was a doctor, who also had a
son called Hugh who took up medicine. All three Peters and both
Hughs, as well as other members of the family, practised obstetrics
extensively and were among the first man midwives of the 15th
and 16th centuries.
In the Middle Ages, Arab physicians referred to instruments for
managing difficult births, but all these had projecting teeth or
hooks so that the baby, if not already dead, died during delivery,
and mothers were often injured too. Alternatively, if internal version
succeeded in turning the presentation to a breech, a hook might be
used to deliver the aftercoming head with the same results. The
invention of an instrument which could deliver a live baby and with
less damage to the mother was therefore an enormous advance.
At the beginning of the last century, New York obstetrician Edwin
Cragin, who coined the phrase once a caesarean always a
caesarean, journeyed by horse and carriage to his patients
confinements at home, bringing his forceps in a velvet-lined case.
Such an air of mystery about obstetric forceps really began with
the Chamberlens, who managed to keep their instrument secret
for more than one hundred years. They did this by bringing the
forceps carefully concealed in a large gilded box when they arrived
at a house for a confinement, performing their deliveries with the
bedsheets tied around their necks and their heads covered by
the blankets. Births must have looked like Ku Klux Klan meetings.
Birthing women always lay in their own soft feather beds into which
they sank deeply, so the application of the forceps, by touch only in
complete darkness, was indeed an art.
In 1813, some of the original Chamberlens instruments were
discovered hidden beneath the floorboards of a house in which
Dr Peter had died many years earlier. All showed the basic pattern of
two blades, revolutionary in its time, fitting together to form a single
instrument, with fenestration of the blades to reduce compression
of the fetal head and a cephalic curve. In later models, there was
an articulation to lock the blades and a tape to tie them together.
It appears that the Chamberlens only ever practised low forceps
deliveries as there was no pelvic curve to their instruments.
The second half of the 18th century saw the development of many
refinements to forceps design, including some by William Smellie,
who introduced a pelvic curve to the blades enabling high forceps
deliveries. A set of Smellies forceps is on display at College House
in Melbourne (see photo on page 20). To make the application of
his instrument more comfortable for the mother, Smellie covered the
metal with leather and greased it with lard before each application.
He was also the first to record the use of the forceps to rotate the
head before delivery and for the aftercoming head of a breech.

During the 19th century many different practitioners experimented
with forceps design the RCOG collection contains several hundred
examples. James Simpson of Edinburgh (who pioneered the use of
chloroform) developed both short and long forceps; Simpsons short
forceps were the forerunner of todays Wrigleys. In France, Tarnier
worked on an axis-traction device for mid-cavity forceps, aiming to
achieve constant and easy traction along the changing axes of the
pelvic planes. His work was the basis of several other axis-traction
forceps, including the Neville-Barnes, familiar to all obstetricians to
this day.
Studies have shown that trainees

now receive little or no exposure
to complex vaginal births and few
have any intention of being involved
in breech deliveries or rotational
forceps as consultants.6,7
Up until the end of the 19th century, forceps were used for one
purpose only the delivery of the child in abnormal obstructed
labour. In 1920, the American obstetrician DeLee proposed the
radical notion of prophylactic forceps, whereby forceps delivery
was performed much sooner, sparing the mother the exhaustion of
prolonged labour. DeLees idea led to the practice of performing
forceps delivery for fetal distress, diagnosed at first by crude
intermittent auscultation by stethoscope and for a range of maternal
indications all of which underpins our practice today.
With a caesarean section rate hovering around 30 per cent, what is
the place of forceps delivery today? A recently published study from
an Australian tertiary hospital found that the instrument associated
with the lowest rates of adverse maternal and neonatal outcomes
was Kjellands forceps.4 This seems crazy, considering Kjellands
forceps fearsome reputation. It shouldnt, because Kjellands
forceps are almost exclusively used with care by skilled practitioners
who know that the stakes are high. As expected, the majority of
deliveries were performed with Ventouse and indeed the outcomes
were excellent for uncomplicated lift-outs. However, once the
Ventouse delivery required rotation, almost one in four attempts was
unsuccessful and the rates of adverse outcome were high. Worst of
all were sequential instrumental deliveries, usually where a Ventouse
was unsuccessful and forceps were then tried. The rates of adverse
maternal and neonatal outcome in those cases were close to two in
three!
Ventouse is commonly seen as safe and thus delegated to
more junior staff. Forceps deliveries are rapidly becoming much
rarer. This means that when a Ventouse either doesnt work or is
contraindicated (for example, when the baby is preterm or there
is little maternal effort) then trainees are often snookered. Their
options are to try forceps, an instrument they have even less
experience with, or to move to caesarean section at full dilatation,
itself a highly morbid procedure.5 Studies have shown that trainees
now receive little or no exposure to complex vaginal births and
few have any intention of being involved in breech deliveries or
rotational forceps as consultants.6,7 Are we heading the same way
with forceps birth?
As a profession, we have reached a critical junction. Huntingfords
prediction may well have come true. Unless a vaginal birth is
likely to be swift and straightforward, a caesarean section will be
performed. The media regale us with stories about climate change,
tipping points and peak oil. Perhaps we have already passed our
tipping point and have passed peak birth. For those left with the
requisite skills, it is probably time not for an earth hour but a birth
hour a summit to urgently examine whether it is worth saving our
skills, or simply consigning them to history.
References
1.
2.
3.
4.
5.
6.
7.
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best

Pract Res Clin Obstet Gynaecol. 2007; 21: 639-55.
Day P, Lancaster P, Huang J. Australias mothers and babies 1995.
1997, AIHW National Perinatal Statistics Unit. Sydney. (Perinatal
Statistics Series Number 6).
Laws PJ, Abeywardana S, Walker J, Sullivan EA. Australias mothers
and babies 2005. 2007, AIHW National Perinatal Statistics Unit.
Sydney. (Perinatal Statistics Series Number 20).
Al-Suhel R, Gill S, Robson S, Shadbolt B. Kjellands forceps in the new
millennium. ANZJOG 2009; 49: 510-514.
Selo-Ojeme D, Sathiyathasan S, Fayyaz M. Caesarean delivery at full
cervical dilatation versus caesarean delivery in the first stage of labour:
comparison of maternal and perinatal morbidity. Arch Gynecol Obstet.
2008; 278: 245-249.
Chinnock M, Robson S. Obstetric trainees experience in vaginal
breech delivery: implications for future practise. Obstet Gynecol.
2007; 110: 900-903.
Chinnock M, Robson S. An anonymous survey of registrar training in
the use of Kjellands forceps in Australia. ANZJOG 2009; 49: 515516.
William Smellies straight obstetrical forceps, c1750. Donated to College House by Prof Robert Kellar, 1955.
20 O&G Magazine
Preventing eclampsia:
art or science?
Edited by Prof Caroline de Costa
FRANZCOG
We are pleased to publish a letter from Dr Richard Lewis, a retired

Fellow of both RANZCOG and RCOG. The arrival of Dr Lewis
letter seemed particularly timely as we prepared this issue of
O&G Magazine. While all of us would believe that our current
management of severe pre-eclampsia is evidence-based, we would
still have to admit that we do not know the cause of the condition.
Dr Lewis describes his time at Sydneys Crown St Womens Hospital
in the mid 20th century, when the Medical Superintendent, Dr Reg
Hamlin, had instituted a system of management of pre-eclampsia
that masterfully combined both science and art. Dr Hamlin later
went to Ethiopia with his wife, Dr Catherine Hamlin, where they
established the Addis Ababa Fistula Hospital. Reg died in 1991
but Catherine, an Honorary FRANZCOG, and now well into her
eighties, still works tirelessly for women with fistulas and the hospital
has recently celebrated its 50th anniversary.
We recommend to readers the landmark 1952 Lancet article
in which Reg Hamlin details his protocols for the detection and
management of pre-eclampsia, and which was widely quoted for
many years following in other journals (link to the article can be
found free online at: www.thelancet.com/). His regimen had seven
steps that he based on careful observation of the condition and he
ensured that these were meticulously followed by all staff, so that he
was able to write: Eclampsia here has been abolished by antenatal
care and the prevalence of pre-eclampsia greatly reduced by means
of (these) measures. Among his stratagems was his method for
dealing with patients who did not turn up for clinic appointments.
Having noted that the worst cases of pre-eclampsia occurred in
bad attenders, he ordered that letters or telegrams be sent to the
women, followed by a visit from the hospital almoner if that failed.
A rather drastic procedure was adopted with those who lived in
distant suburbs and did not replyThe nearest police station was
telephoned and the police asked to deliver the message that an
immediate visit to hospital was expected. Excellent results followed
this procedure in most instances.
This is a remarkable article by a very remarkable man. We thank
Dr Lewis for his contribution to this edition of O&G Magazine.
Medical pamphlets
RANZCOG members who require medical
pamphlets for patients can order them through:
Mi-tec Medical Publishing
PO Box 24
Camberwell Vic 3124
ph: +61 3 9888 6262
fax: +61 3 9888 6465
Or email your order to: orders@mitec.com.au
Dear Editors,
The excellent editorial in The Australian and New Zealand
Journal of Obstetrics and Gynaecology (June 2009)
emphasising the significant morbidity and mortality associated
with pre-eclampsia was reinforced by my meeting recently with
two friends of my wife, one of whom has been having renal
dialysis three times per week for many years following eclampsia
30 years ago. The other lady told me about her 34-year-old
granddaughter, who in her first pregnancy with twins fitted 15
hours post-caesarean section. She had developed signs of preeclampsia at 35 and a half weeks but was sent home after two
days of hospitalisation, only to return days later with severe preeclampsia requiring immediate delivery. Three years later, she
has no residual kidney problems or heart failure, but she made
the comment that in her antenatal classes no mention was made
of pre-eclampsia or its potential dangers.
I was fortunate to be a member of the resident staff during
Dr Hamlins time as Medical Superintendent at Crown Street.
I was impressed by the man and his ability to unify his team
of medical and nursing staff. He laid down parameters for the
supervision of patients having antenatal care and confinement
at the hospital that were strictly observed. At his request, he
was informed on each occasion of every booked patient whose
findings were outside these parameters and they were treated
with an appropriate regime. He personally saw all these patients
during their time in hospital. I can vouch for the fact that in
the two years I was there, we had 10,000 deliveries of booked
antenatal patients without one case of eclampsia.
Dr Hamlins 1952 article tells how eclampsia can be prevented.1
By following his teaching, over a 40-year period of obstetric
practice, I was fortunate in not having one mother develop
eclampsia.
It would seem helpful if midwives lectures to pregnant women
contained some mention of pre-eclampsia, emphasising that
severe pre-eclampsia/eclampsia is not a common condition but
is still a dangerous one.
Richard R.J. Lewis

FRANZCOG, FRCOG
1.
Hamlin, RHJ. The prevention of eclampsia and pre-eclampsia.

Lancet 1952; 1(6698):64-68. (www.thelancet.com/)
You can also download the order form from the

RANZCOG website: www.ranzcog.edu.au .
Standards of
antenatal care
The development of modern obstetric care demonstrates clear survival benefits
for the fortunate who can access it. However, the evidence accumulated in the
West cannot automatically be transferred to poorly-resourced communities
elsewhere.
Dr Celia Devenish
FRANZCOG
Western style obstetric care grew from

ancient observational knowledge and
practices. More recently, over the
last three decades, evidence-based
obstetric practice has emerged.
Antenatal care is provided to a
wide range of women from varied
backgrounds, each with different
individual needs. How can care best
be provided in light of the changing
preferences and needs of societies?
All of the following remain important
topics for debate.
What should be the standard of antenatal care for pregnant

women? Which pregnancies should be seen? What constitutes a
higher risk pregnancy? How often and by whom? Is our current
routine practice evidence-based? Is pre-pregnancy a better time for
initiating individual risk assessment?
What information should be shared and how is this best done? In
a free-to-all service, how is the level of care decided? How do we
address the need for equity of care access around the world, given
the wide variance of resources?
While antenatal care is not new, the concept of universal access to
free maternity care as an investment by society is relatively new. It
started in 1943, with the New Zealand National Health Service
and was followed in 1948 by a similar British system, spreading
in some form to other countries. This concept, that maternal and
fetal health is seen as a desirable investment for undeveloped parts
of the world, is illustrated by the recent United Nations resolution
to support Ghana and other African nations embarking on a free
national maternity service.
The body of knowledge passed down to individual medical
practitioners of midwifery became concentrated in teaching from
the first lying-in hospital in 1739 at Queen Charlottes Hospital in
Jermyn St, London.
A clinical guide to Best Obstetric Practice was subsequently
published. In the second edition of 1930, the definition of antenatal
care was, the whole art of preventive obstetrics, which stands
today. The purpose of this art entailed a careful watch of the
woman throughout pregnancy, with immediate institution of action
whenever the least departure from the norm is detected.
Even in the 1930s, many of the then known dangers to women were
considered preventable. Watson states: The stillbirth rate falls 50
per cent with proper antenatal supervision and the death rate from
toxemias, haemorrhages and labour complications is considerably
diminished.
22 O&G Magazine
The nature of the dangers to women and their pregnancies have

changed considerably over time. In Europe, 80 years ago, rickets,
tuberculosis and scarlet fever were key risks to the survival of women
and their fetus. Obstructed labour meant death sooner or later
and confinement was often accompanied by haemorrhage and
puerperal infections.
Todays concerns and avoidable risks in western society are
different to those described by these early obstetricians who
practised the art of midwifery, although women of the developing
world retain these same risks. Today, raised BMI with attendant
diabetes and co-morbidities together with hypertension are
increasing risks to preganancies. Women choose to defer
conception into the third and fourth decades and such delayed
fertility brings its own problems. Assisted reproductive techniques
allow pregnancies in circumstances never previously possible. Both
developed and undeveloped nations experience the complications
of HIV and hepatitis C.
There are several sources of woman-centred antenatal information
which are evidence-based on both the RANZCOG and RCOG
websites, with 18 Green-top Guidelines on aspects of antenatal
care, often with lay person summaries.2 The evidence-based NICE
guidelines are extensive with recommendations frequently updated.3
In 2001, the Three Centres Consensus Guidelines on Antenatal
Care 4 commented on the following basic care issues: appropriate
number of visits; models of care; smoking cessation; asymptomatic
bacteruria; routine investigations; measurement of blood pressure
and symphyseal fundal height (SFH); urinalysis by dipstick;
auscultation of the fetal heart; gestational diabetes mellitus (GDM);
group B streptococcal disease (GBS); hepatitis; HIV; syphilis; and
rubella screens.
The RANZCOG guideline C-Obs 30: Suitability Criteria for Models
of Care and Indications for Referral Within and Between Models of
Care5 and the New Zealand Section 88 guidelines6 advise on the
best practice surrounding referral to secondary care.
Table 1 (opposite) summarises the current evidence for aspects of
antenatal care relevant to practice in Australia and New Zealand.
We constantly review the way in which we practise obstetrics as part
of ongoing professional development and the information we use is
constantly being updated.
There is increasing evidence that the secondary care referral for
pre-existing medical and prior obstetric referrals are best made
before conception with a multi-disciplinary team approach.
RANZCOG (C-Obs 30)5 and the New Zealand Section 88
guidelines6 offer clear guidelines for appropriate referral of women
to specialists.

Table 1. Current evidence for aspects of antenatal care in Australia and New Zealand.
Topics
Recommendations
Breastfeeding
Both group and individual sessions are effective. Follow through into postpartum is
important.
Diet
Interventions to limit weight gain reduce GDM* (Olsen 2007).
Smoking cessation
Effective use of nicotine (Rigotti 2006).
complications
Breech, ECV*, twins,

hypertensive syndromes, VBAC
high head, post-maturity, etc
Benefit from individual counselling by specialist.

It is important to document and communicate in regard to plans.
Maternal screening
Past obstetric and family history
Accurate documentation gives best risk assessment.
BMI assessment
GDM recognition. Allows advice in regard to limitation of weight gain.
STI and BV*
Reduces prematurity and fetal complications.
Blood haemoglobin (Hb)
Anaemia detection, haemoglobinopathies, rhesus antibodies, reduced blood

transfusions.
Previous infections
Rubella, syphilis, hepatitis C, HIV. Allows for appropiate interventions.
Polycose
GDM diagnosis improved.
Domestic issues
Use of screening questions improves recognition.
Mental health
Benefits of ALPHA program/direct questioning improves outcomes.
Urine dipstick
Proteinuria in community automated point of care testing recommended for

preeclampsia detection.
Anomaly screening
Decision aid and leaflets both effective for pregnancy screening (Graham 2000 Becker
2004). Women prefer one on one discussions.
Gestational age confirmation
First trimester dating and viability, assists induction of labour (IOL) and other decisions.
Fetal growth
Scans and Doppler assist identify FGR*.
SFH* measurement
Incomplete evidence regarding benefits. Individualised GROW charts.
Fetal heart auscultation
No benefit over fetal movement enquiry. Reassurance only.
Education
Late pregnancy
Fetus
Examination
* GDM = gestational diabetes mellitus

* ECV = external cephalic version
* SFH = symphyseal fundal height
* BV = bacterial vaginosis
* FGR = fetal growth restriction
Careful documentation and explanation of the outcomes of such

discussions is very important, so that management plans can be
accessed as required.
All this evidence is, however, fruitless without good lines of
communication, both with the woman and with other members
of the team. Communication is the essential art which enables
wisdom and good practice to reach all women, whatever their
circumstances.
Antenatal interventions NOT routinely recommended:
Repeated maternal weighing
Breast or pelvic examination
Iron or vitamin A supplements
Routine screening for chlamydia, cytomegalovirus, hepatitis C
virus, group B streptococcus
Toxoplasmosis, bacterial vaginosis
Routine Doppler ultrasound in low-risk pregnancies
Ultrasound estimation of fetal size for suspected large-forgestational-age unborn babies
Routine screening for preterm labour
Routine screening for cardiac anomalies using nuchal
translucency
Gestational diabetes screening using fasting plasma glucose,
random blood glucose, glucose challenge test or urinalysis for
glucose
Routine fetal-movement counting

Routine auscultation of the fetal heart
Routine antenatal electronic cardiotocography
Routine ultrasound scanning after 24 weeks.
References
1.
RANZCOG Statements (www.ranzcog.edu.au/womenshealth/

statementsupdate.shtml).
2. Green-top Guidelines (www.rcog.org.uk/womens-health/guidelines).
3. NICE Guidelines (www.nice.org.uk/guidance/index.jsp?action=byType
&type=2&status=3).
4. Three Centres Consensus Guidelines on Anrnatal Care 2001 (www.
health.vic.gov.au/maternitycare/anteguide.pdf).
5. www.ranzcog.edu.au/publications/statements/C-obs30.pdf .
6. www.moh.govt.nz/maternity .
7. NHS Evidence on Antenatal Care update (www.library.nhs.uk/
womenshealth).
8. Sarris, Bewlwy, Agnihotri. Training in Obstetrics and Gynaecology.
Oxford 2009.
9. Womens Health Specialist Library Antenatal Care National Knowledge
Week 2008 (www.library.nhs.uk/SpecialistLibrarySearch/Download.
aspx?resID=294928).
10. www.sign.ac.uk .
11. www.dh.gov.uk .
Antenatal classes
A New Zealand patients perspective
Anonymous
I approached my own antenatal classes with some wariness, as
a medical graduate, but having become very rusty on all things
obstetric in recent years.
My experience was a very positive one, with a course tutor who
dealt ably with a diverse group. I felt it was fair to identify myself
to the tutor as a doctor early on, but was very happy to be treated
as one of the group, rather than being called on or expected
to provide a medical perspective. In what must be a common
experience for many health professionals, this relief was balanced
against some sense of responsibility to let the tutor know if I had any
major concerns about the course content, as it related to my area of
expertise. Fortunately, this did not arise, other than my concern that,
rather than being advocated for, immunisation was presented very
neutrally as an option that parents may wish to pursue.
The course included material on physical changes during
pregnancy, including a session from a physiotherapist; labour and
birth; different aspects of birth (pain relief, assisted birth, caesarean
and induction); breastfeeding; and adjusting to life at home with a
newborn. The breastfeeding session provided comic opportunities,

with the men attempting the various holds with dolls predictably,
the rugby-hold was deemed the most manly. A reunion held several
months after the completion of the course provided an opportunity
to compare both experiences and babies.
The course content was well-pitched to an audience with a wide
range of knowledge, with user-friendly handouts provided. In terms
of breadth, in the months since having my baby, I and other new
parents I have spoken to have felt that the course could place
greater emphasis on the adjustment to parenthood. This is especially
so for those of us who have had rocky starts with breastfeeding and/
or sleeping. To some extent, however, I wonder if both are cases of
learning most effectively by doing, with the assistance and support
of the lead maternity caregiver and other health professionals, such
as Plunket family centres. My local womens and childrens health
service does offer additional antenatal breastfeeding classes, which
I did not attend, but have recently heard very positive feedback
about. Hindsight is a wonderful thing.
An Australian patients perspective

Anonymous
My son is now almost 15 months old so my memory of the
antenatal classes I attended in Melbourne has faded somewhat.
Therefore I can really only talk in general terms about my overall
impressions of the antenatal class experience and some things that
have stuck in my mind since.
Its probably useful to know that I have a professional background
in health and had done quite a bit of background reading on
pregnancy, childbirth and breastfeeding prior to attending the
classes. I had also scoured the website of the hospital where my son
was to be born for information and images of the birthing suites
and any other information that might have been useful or relevant.
Therefore, I was rather uncertain about how much the classes might
contribute to my knowledge and understanding. However, I was still
very much looking forward to the classes and was very pleasantly
surprised at the value I gained from attending.
Overall, I recall the classes being well-paced, with some funny
moments and a pretty good mix of didactic and interactive delivery.
I recall some of the main topics covered included the niggles and
inconveniences of pregnancy, birth, pain relief options available,
breastfeeding, where to find support after the birth and the needs
of a newborn. The classes provided a great opportunity to talk
with other women (and their partners or birth support person)
about their experiences of a first pregnancy. The component that I
most anticipated was the tour of the hospitals delivery suites and
24 O&G Magazine
postnatal ward rooms. The opportunity to see the facilities was a far
superior experience to looking at a few low resolution web images!
I would also like to mention that at the time I did not have a partner,
so I was launching myself into the world of single parenthood and
in a country (Im an ex-pat Kiwi) where I had no family support.
Going it alone and the prospect of single parenthood had at times
created some stress and had also made me somewhat sensitive
to any discriminatory language or actions from others, intended
or otherwise. Having said that, I remember being pleased and
impressed by the consistently impartial and inclusive approach taken
by the staff who ran the classes. Perhaps this should be a given in a
class delivered by a public health service, but I think it is still worth
highlighting when it is noticed and appreciated.
The only comments I have regarding possible improvements would
be to have, when possible, the same staff member delivering all
three of the sessions and clarity about whether the information
provided was evidence-based and what evidence-based means in
lay terms.
Non-pharmacological pain
management in childbirth
Collated by Dr John Schibeci
DRANZCOG
One of the triumphs of Western medicine has been in the areas of

analgesia and anaesthesia. Think James Simpson, John Snow and
Bayer Aspirin. The pain of childbirth is usually put down as a ten
on the Richter scale of pain and hence modern medicine, with its
pharmacology of analgesic choices, comes to the rescue and often
succeeds.
Water and birth. Folklore or fad?
To some women, the pain of labour and childbirth is seen as a rite

of passage, whereas to other women, it is something which needs to
be stopped dead in its tracks.
The following group of articles look at some of the alternatives to
the pharmacological management of labour pain. Each modality is
steeped in its own history and also triumphant in its contribution to
managing labour pain for many more centuries than the epidural
and nitrous oxide. After reading these articles, one will realise that
there is more to managing the pain of labour than simply naming
your poison.
Louise Homan
Women who experience water birth report, anecdotally,

satisfaction with their birthing experience and a sense of pride,
empowerment and achievement. What greater achievement for
a mother than for her newborn baby to be welcomed by her own
touch?
Since ancient times, women have used water for comfort,

relaxation and as a means of easing the pain of labour. A study
of the culture of childbirth demonstrates that the use of water has
a significant role in the birth process, past and present.
References
Registered Nurse/Endorsed Midwife
On some islands in the South Pacific, women went down to the

sea to give birth in the shallows. In New Zealand, the women
of one Maori tribe in the hills gave birth in a sacred river. When
labour is difficult in rural Greece, the midwife or the assisting
woman may pour water through the sleeve of the husbands shirt
or down the chimney. In Jamaica, the nana soaks a cloth in hot
water and cocoons the birthing mother within it.2
It is somewhat surprising then that the use of water during labour
and birth has been viewed with some trepidation in contemporary
medical models of midwifery and obstetric practice.
...evidence suggests that water immersion

and underwater birth potentially offer both
physical and psychological benefits to
labouring women.1
While the risks and benefits of water immersion in the second
stage of labour requires further research, available evidence
suggests that water immersion and underwater birth potentially
offer both physical and psychological benefits to labouring
women.1
These outcomes are easily overlooked in a healthcare system with
a strong focus on the financial factors that determine how birth
occurs.
With water birth, the mothers choice of birth place is met,
enabling a feeling of privacy and ownership of her own body and
labour. Her instinctive movements are unencumbered and a lower
technology profile lessens fear and anxiety.
1.
2.
Cluett ER, Burns E. Immersion in water in labour and birth.

Cochrane Database of Systematic Reviews 2009, Issue 2 Art No.:
CD000111. DOI: 10.1002/14651858. CD000111.pub3.
Kitzinger, S. Rediscovering Birth. Little, Brown and Company (UK).
2000 London.
Intradermal injections of water

Kimmy Brooks
Senior Midwife
Royal Hobart Hospital, Tasmania
Since 2006, Royal Hobart Hospital has provided nonpharmacological pain relief in the form of intradermal injections
(IDI) of sterile water for the relief of acute backache in labour. It is
reported that 30 per cent of labouring women experience acute
back pain. It is distressing for the women and all those involved if
the pain cannot be relieved.
IDI is simple to learn and was originally used for relief of pain in
renal colic and whiplash. Midwives in Scandinavia adopted and
adapted the technique in 1987. IDI has been used in Canada
and the United States since 1991 and was introduced into
Australia around 2002 by Janice de Campo, a clinician from
Colac, Victoria.
The general consensus is that this technique works either by the
gate control theory or through the release of endogenous opioid
endorphins. The woman receives four injections with 0.2 to 0.5ml
of sterile water just under the skin to produce a papule over the
sacro-iliac joints. The exact injection sites are not crucial to its
effectiveness. As the injections are very painful, it less traumatic

if two injections are administered by two people simultaneously.
Most women report achieving rapid, dramatic and often complete
relief of back pain in labour. The analgesic effect usually lasts 60
to 90 minutes.1
Transcutaneous Electrical Nerve

Stimulation (TENS)
While this form of pain relief will not suit all women experiencing
back pain, it does offer choice to those women not wishing to use
narcotics or epidurals.
Labour TENS
Reference
1.
Reynolds JL. Practice tips. Intracutaneous sterile water injections

for low back pain during labour. Canadian Family Physician1998;
44:2391-2.
Acupuncture not a new age treatment

Judy James
CEO
Australian Acupuncture and
Chinese Medicine Association Ltd
Acupuncture has a long history of safe and effective use in

pregnancy and childbirth, both in Australia and in China, as well
as in other parts of East and South East Asia. Its use is based
on a well-established coherent body of knowledge, known as
Traditional Chinese Medicine (TCM), that forms the basis of its
clinical practice. In addition to its documented traditional use,
there is a growing body of sound research evidence supporting
the safety and efficacy of acupuncture in the treatment of
pregnant and birthing women. Acupuncturists are increasingly
working alongside the supervising midwife and obstetrician in
providing safe and effective support for pregnant and birthing
women.
In pregnancy, acupuncture is primarily used for the treatment
of morning sickness, threatened miscarriage and correction
of breech position. The latter does not involve any manual
manipulation of the fetus. Pregnant women may also seek
acupuncture as a safe drug-free intervention for the treatment of
a range of pregnancy-related conditions such as insomnia, back
pain and mild depression, as well as for non-pregnancy related
health conditions or for general wellness support.
In obstetrics, the use of acupuncture focuses on cervical ripening
and induction in delayed or prolonged labour, as well as for pain
management.
Various trials and reviews have found that there are no increased
risks associated with the inclusion of acupuncture as an
intervention in pregnancy and childbirth.
Nevertheless, it is recommended that acupuncture services
be obtained only from persons who are suitably qualified and
trained in its safe and competent use. The Australian Acupuncture
and Chinese Medicine Association Ltd (AACMA) current entry
requirement is a four to five-year approved bachelor degree
program with a major in acupuncture.
More information can be obtained from AACMA at:
www.acupuncture.org.au .
Heather Greer
What is TENS and how does it work?
Transcutaneous Electrical Nerve Stimulation (TENS) is a small
portable battery-powered device for relieving pain. It sends a
pulsed electrical stimulus to the nerves via electrodes, which are
adhered to the skin. TENS broadly works in two ways:
Firstly, it exploits Melzack and Walls6 gate control theory of
pain. TENS stimulates the A-beta sensory nerves. This activity
in the large nerve fibres activates the inhibitory interneuron,
which blocks the projection neuron and therefore stops the
ascending pain impulse. If the A-beta input continues to
exceed the nociceptor input the virtual gate remains closed
to pain.
Secondly, TENS also excites the higher centres causing the
systemic release of endogenous opioids.1
Why use a Labour TENS?
TENS are often used by physiotherapists to treat pain and
injury, however, these conventional or rehabilitative TENS
are inadequate for childbirth. A Labour TENS is specifically
designed for obstetrics with pre-set programs which manage
the pain shifts and intensity of labour with a boost button. This
boost automatically increases the amplitude by 20 per cent
and switches the program to a boost mode (continuous high
frequency) for intense pain relief needed during a contraction.
After a contraction, the button is depressed again to switch back
to rest mode (low frequency), a gentler program providing the
gating effect and maintaining the level of endorphins. Labour
TENS is self-administered and the level is titrated according to
need. The effects are immediate and long-lasting, with over 80
per cent of women achieving pain relief. There are virtually no
side effects and no known potential for overdose.2 TENS is low
cost (A$65 for five-week hire or $195 to purchase) and can be
rented or purchased without prescription with health fund rebates
of up to 100 per cent.
Precautions and side effects
Skin irritation can occur under electrodes in two per cent of
patients. TENS should not be used for patients with a pacemaker.
TENS should not be used or submerged in water. For more
information: www.labourtens.com.au .
How is Labour TENS used?
For optimum effect, Labour TENS is used at the onset of labour
and for two to three hours afterwards.
Self adhesive electrodes are fixed to the lower back (the top pair
of electrodes paravertebrally at T10-L1 and the lower pair at S2
to S4). Labour TENS is then switched on and set to the required
amplitude. The level can be adjusted to maintain a strong yet
comfortable level as required, with the ability to set each channel
individually. The hand held boost button is used for switching
between rest and boost mode.
During the early stages of labour and in between contractions,
rest mode is used for mild pain relief. For strong contractions, the
button is pressed to increase pain relief. The Labour TENS display
indicates the selected mode and intensity.
Continued on page 27.
26 O&G Magazine

As TENS may vary, refer to the operators manual for complete
instructions.
HypnoBirthing eliminates the fear-tension-pain syndrome

before, during and after birthing.
Summary of the benefits of Labour TENS:

It can be used alone in all stages for a drug-free birth or
adjunct medication.3
It relieves pain and speeds recovery from caesarean section.4
Over 80 per cent of women achieve high levels of pain relief.7
Women can manage their own pain with the dosage titrated
according to need.
It reduces post natal pain, vaginal and perinea trauma.5
No drowsiness and few side effects for mum or baby.2
It reduces the length of the first stage of labour.3
35 years research, experience and proven safety record.
Cost-effective with health fund rebates of up to 100 per cent.
Non invasive therapy that allows the mother full movement.1
Understanding the way in which the uterus functions naturally

when unencumbered by fear, the concept of easier, more
comfortable birthing immediately becomes obvious. This concept
is the key to the entire HypnoBirthing program.
References
1.
2.
3.
4.
5.
6.
7.
Johnson MI. Transcutaneous Electrical Nerve Stimulation:

Mechanisms, clinical application and evidence. Reviews in Pain. The
Educational Supplement from the British Pain Society 2007; 1(1);
7-11.
Johnson MI, Bjordal JM. Non-pharmacological approaches to
pain management. In: A Dickman, KH Simpson (eds). Oxford Pain
Management Library: Chronic Pain. Oxford University Press 2008;
pp119-129.
Kaplan B, Rabinerson D, Lurie S, Bar J, Krieser UR, Neri A.
Transcutaneous electrical nerve stimulation (TENS) for adjuvant
pain-relief during labor and delivery. International Journal
Gynaecology and Obstetrics; March 1998; 60(3):251-5.
Kaplan B, Rabinerson D, Pardo J, Krieser RU, Neri A.
Transcutaneous electrical nerve stimulation (TENS) as a pain-relief
device in obstetrics and gynaecology. Clinical and Experimental
Obstetrics & Gynecology 1997; 24(3):123-6.
Lorenzana FD. A randomized controlled trial of the efficacy of
transcutaneous electrical nerve stimulation (TENS) versus lidocaine
in the relief of episiotomy pain. Philippine Journal of Obstetrics &
Gynecology 1999 Oct-Dec; 23(4):135-42.
Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;
150:971-979.
Verity Medical (2003). Neurotrac Labour TENS Operators Manual.
View at: www.medicalverity.co.uk .
HypnoBirthing
Susan Ross
HypnoBirthing Practitioner
Designed by a hypnotherapist, Maree Mongan, in the United

States, this program is not just for labour and birth, but a
powerful lifeskill which can be learned.
HypnoBirthing is as much a philosophy as it is a technique. It is
a rewarding, relaxing, stress-free method of birthing that is based
on the belief that all babies should come into the world in an
atmosphere of gentility, calm and joy. When a woman is properly
prepared for birthing physically, mentally and spiritually, she can
experience that sort of joy, birthing her baby in an easier, more
comfortable and often pain-free manner. Through a well thoughtout program of deep relaxation, self-hypnosis and education,
HypnoBirthing returns to a woman the art of birthing in a way
that allows her to summon her natural birthing instincts and to
birth her baby in safety and with ease.
Hypnosis is a means of inducing a level of consciousness that

is characterised by relaxation and suggestibility. The purpose of
hypnosis is to provide a means of bypassing the critical mind
and accessing the non-reasoning, suggestible subconscious.
Hypnosis allows us to zoom in on limiting thoughts.
Hypnosis releases thoughts that could interfere with birth.
The mind determines what and when the body feels.
Following HypnoBirthing principles means that birthing is
returned to the safe, beautiful, peaceful experience that nature
intended.
Reference
1.
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous

support for women during childbirth. Cochrane Database of
Systematic Reviews 2007, Issue 2. Art. No.: CD003766. DOI:
10.1002/14651858.CD003766.pub2).
Calmbirth
Tracey Anderson Askew
Accredited Childbirth Educator

Registered Calmbirth Facilitator
Calmbirth prepares couples for birth and parenting from

antenatal education through to birthing and parenting wisdom.
The Calmbirth program assisted me greatly with the birth of

my first child. Calmbirth helped me relax during the birth and
the breathing techniques were instrumental, I feel, in making the
birth quick and easy. I strongly recommend the program as it
encourages women to listen to, and assist their bodies, to birth
their babies. Jenny
We couldnt have asked for a more relaxed and calm birth
with medical support. While they were getting me ready for
the caesarean section, I focused on my special place in nature
and did the calm breathing. When it was time for me to have
the spinal block, I increased my deep breathing and went even
deeper into myself. John told me later that the anaesthetist made
the comment that I would be a great case example for other
women having a caesarean section on how to remain relaxed
during a spinal block. Natasha
Jenny and Natasha, like a growing number of Australian women,
used the Calmbirth technique to facilitate a positive birth
experience. Calmbirth is a unique 12-hour antenatal Australian
childbirth education program developed in 2005 by Australian
midwife Peter Jackson to reduce pain during the birthing process
by eliminating fear and tension. In his 30 years as a nurse, Peter
witnessed many mothers whose experience of childbirth was
one of fear, pain and trauma. As a result, he began to search
for ways to help improve the experience of these mothers. His
method promotes the use of the subconscious resources of

deep relaxation which centre around the normal physiological
relaxation responses within the body. The techniques can be
employed by women who have a vaginal birth or caesarean
section.
Calmbirth helps women and their partners

understand and address these fears and
uses breathing, visualisation, mind-focusing
techniques, massage and touch to relax the
body and mind in preparation for birth and
parenting.
During pregnancy and prior to the birth of their baby, many
women experience a degree of fear or anxiety about becoming
a parent. These fears can interfere with the bodys natural
responses to the process of labour, birth, bonding and
breastfeeding. Fear of childbirth has been linked with emergency
caesarean section, dystocia and protracted labour.1 Research has
also demonstrated that women with antenatal fear of childbirth
have an increased risk of developing perinatal depression, with
possible implications for their relationship with their new baby.1
Calmbirth helps women and their partners understand and
address these fears and uses breathing, visualisation, mindfocusing techniques, massage and touch to relax the body and
mind in preparation for birth and parenting. Partners move
from being observers of the experience to having a clear role in
supporting, encouraging and assisting their partner in labour.
When practised regularly, the skills that women and their partners
acquire during the Calmbirth course continue to support them
during times of stress throughout their lives.
Although there has been no formal research to support the direct
effect of Calmbirth on labour and birth outcomes, responses
collected on pre- and post-Calmbirth course evaluations have
clearly indicated a high level of satisfaction and usefulness with
what participants experienced during the classes and an improved
emotional state of pregnant women. Table 1 indicates that prior
to completing the Calmbirth course, only 14.7 per cent of
women felt either confident or very confident with their impending
birth, but at the completion of the course, this figure had risen to
83.8 per cent. Further research is warranted to explore the effects
of Calmbirth on labour and birth outcomes.
Table 1.
Participants describe their thoughts about birth before and after
completing the Calmbirth course.
Before Calmbirth
course
%
no.
After Calmbirth
course
%
no.
Very frightened 8.8%
(56)
Frightened
7.4%
(47)
0.2%
(0)
(1)
Anxious
38.8%
(247)
2.2%
(14)
Neutral
9.6%
(61)
1.4%
(9)
Ok
19.7%
(125)
9.3%
(59)
Confident
13.1%
(83)
48.0%
(305)
Very confident
1.6%
35.8%
(228)
To conclude, information alone will not significantly prepare a

couple for the experience of birth and parenthood.3 Creating
changes in perception and behaviour, through understanding,
28 O&G Magazine
direct experience and the practising of new skills is required. The

Calmbirth course challenges participants fears and facilitates
this process.
The Calmbirth course is facilitated by registered practitioners,
with qualifications in midwifery, childbirth education or health. For
more information go to the website: http://calmbirth.com.au.
References
1.
2.
Laursen M, Johansen C, Hedegaard M. Fear of childbirth and risk

for birth complications in nulliparous women in the Danish National
Birth Cohort. BJOG 2009; 116: 1350-1355.
Gagnon AJ, Sandall J. Individual or group antenatal education
for childbirth and parenthood or both. Cochrane Database of
Systematic Reviews 2007, Issue 2. Art No. CD002869. DOI: 10.
1002/14651858. CD002869. pub2.
Doula
Susan Ross
Director, Birth Right
What is a doula? She is the key to a woman having a wonderful

birthing experience. Professionally trained to provide emotional
and physical support for a woman during pregnancy, labour,
birthing and post-natally. Doula is a Greek word meaning
mothering the mother.
Research shows that women who have a doula have decreased
rates of medical intervention, higher satisfaction rates and
increase in breastfeeding rates.1
A doula gets to know a couple on a different level. She has the
time to understand what a woman wants for her birth and to
advocate, support and encourage. She also provides a lot of
support for the father. A doula allows the father to be involved
to his own comfort level. Being able to reassure a couple and
normalise the experience for them, eliminating any lingering fears
and anxieties, allows labour to progress with grace and ease.
Doulas work closely with midwives and obstetricians.
What some men say about having a doula:
Nigel: She was present without being a presence. This is such
a powerful statement and highlights the essential qualities of a
doula.
Jason: Having a doula there gave us the confidence to stay at
home for longer, rather than rushing in to hospital immediately.
The support was amazing.
What some women say about having a doula:
Jacqui: It is difficult to explain the power of having someone
so strong and centered and experienced lending balance
and authority during the extremes of labour supporting
your decisions, suggesting techniques to help with labour and
reminding you of your own strength and capability.
Sarah: Having such a positive birth experience was wonderful,
but also incredibly valuable in leaving me emotionally and
physically able to embrace the whirlwind of new motherhood.
Having a doula made the difference.
Every Pregnant Woman Deserves a Doula.
Planned homebirths in
Australia
Art, science...or politics?
Dr Andrew Pesce
FRANZCOG
Obstetricians either specialists or general practitioners all seem to mix a

little art with their science. We usually aim to keep our practices in line with
recommendations from the literature, but most of us let a little art sneak in too.
Fortunately, Australia is a very safe place to have a baby and for

babies to be born, so as a profession we are obviously getting the
mix right most of the time.
Anybody who has picked up a newspaper or listened to a news
bulletin during this year will have seen some of the very public
debate that is playing out over planned homebirth in Australia.
The Maternity Services Review (MSR) document, released earlier
this year, recommended that support should not be provided for
homebirth in this country. Although the MSR had no comment about
whether planned homebirth should be considered a safe model of
care for women in Australia, the lack of a recommendation actually
reflected the lack of consensus between the various providers of
pregnancy care that would be necessary for safe homebirth.
Birth is obviously less about

science to many members of our
communities and more about
humanity.
The heated emotions that characterise the homebirth debate were
further inflamed when Parliament considered legislation requiring
that appropriate indemnity insurance be carried by all health
professionals registered to provide care in Australia. The intention of
this legislation was not to stop midwives from attending homebirths.
However, the fact that indemnity insurance for homebirth was
unavailable meant that any midwife attending a planned homebirth
would have had to either relinquish registration with a nursing and
midwifery board, or face the risk of penalties.
Most obstetricians seek evidence to guide them and the published
literature reveals that planned homebirths in Australia are associated
with a higher risk of intrapartum mortality.1 A study published in a
very recent edition of the Medical Journal of Australia, examining
the outcomes of over 1100 planned homebirths undertaken over
15 years in South Australia, has revealed some startling findings.2
Planned homebirths are, in general, lower risk pregnancies,
yet the rate of intrapartum mortality was seven times higher
than planned hospital births. Even more alarmingly, the rate of
perinatal death due to intrapartum asphyxia was 27 times higher,
with the differences reaching statistical significance despite the
relatively small study group. After standardisation for gestation
and birthweight, the perinatal mortality was more than twice that
of hospital births, but because of the small number of births the
differences were trends and did not reach significance.
Anybody involved in pregnancy care knows that severe adverse

outcomes for babies are an unavoidable consequence of birth
sometimes. The data from South Australia suggest that births
planned for hospital settings are statistically less likely to result in
death than those planned for homes. The other remarkable fact
to come out of the study was that while the decade from 1976 to
1987 saw a halving of perinatal asphyxial death rates in South
Australia, the rate for homebirths barely changed. Unsurprisingly,
the rates of important interventions such as caesarean section were
higher in hospitals, but the confounding effect of pre-existing risk
could not be accounted for, so it is difficult to make a comment.
It is difficult to know what to do with such information. Birth is
obviously less about science to many members of our communities
and more about humanity. Some have argued that these poorer
outcomes of homebirth, when compared to hospital birth, result
from inappropriate inclusion of higher-risk pregnancies as planned
homebirths. If genuinely low-risk pregnancies are cared for in home
settings and care is provided by accredited practitioners, so the
argument goes, then things will be different. Certainly hospitalsupported homebirth models have been adopted by several statebased health services.
The Australian Federal Health Minister faced highly-publicised
pressure to put the MSR recommendations aside and devise a
way of providing indemnity insurance, and indeed specific funding
for planned homebirths. In the end, a political compromise was
reached in which registered midwives were exempted from the
requirement to carry indemnity insurance (as every other registered
healthcare provider must), but the called-for financial support did
not materialise. The political decision thus sidesteps the evidence
that, as presently practised, planned homebirth is associated with
increased risks of perinatal death, while acknowledging that a
few Australian women will continue to aim for birth at home. The
pragmatists among us will realise that it is safer that this group
have care from midwives that have undertaken freebirthing, as
unassisted birth is known colloquially.
We have come a long way, moving

incrementally from pure art to
science (that still has a little aesthetic
appeal).
Like all political compromises, nobody is really satisfied. Homebirth
advocates wanted indemnity and funding and missed out.

Opponents remain hot under the collar that professional standards
appear to have been altered to appease the noisy minority. In
the end, little has changed midwives who carry no insurance
continue to manage homebirth with no risk of professional
penalties, provided they disclose to their clients that they are not
indemnified. Yet at the same time, the evidence we have from
studies of homebirth in Australia should make us uneasy. How
many obstetricians would advocate managements that they know
are associated with increased risks of death, then sacrifice their
indemnity cover in order to be able to perform them?
Fortunately, the new arrangements include obligations to provide
data to health authorities and to participate in a safety and quality
scheme. This will, presumably, allow for a good quality prospective
data collection (including morbidities for mothers and babies).
Over the past decades, obstetrics has cleaned up its act with
regards to evidence-based practice. The symbol for the Cochrane
Collaboration is derived from the forest plot that revealed the
benefits of corticosteroids for fetal lung ripening. We have come
a long way, moving incrementally from pure art to science (that
still has a little aesthetic appeal). Let us hope that birth in Australia
continues to provide the new generation with the safest possible
start to life.
References can be obtained from the author upon request.
CPD Self-Education
Activities
Have you been involved in developing or
reviewing guidelines and protocols?
Did you know you can claim CPD points in the
self-education category?
Have you changed your address or

email account recently?
Have you notified the College of
these changes?
Download a form from
the College website at:
www.ranzcog.edu.au/fellows/cpdselfeducation.shtml
If you have been further involved with the implementation and audit of
the effectiveness of the guideline/protocol, you can claim this time spent
in the PR&CRM category at the rate of one point per hour.
30 O&G Magazine
If not, please update your contact details

via the RANZCOG website (www.ranzcog.
edu.au) and follow the link to Update
contact details or call 03 9417 1699 to notify
the College of your changed contact details.
Homebirth transfers at
Lismore Base Hospital
A retrospective review
Dr Brendan OSullivan
FRANZCOG
Dr Tony Bushati
RANZCOG Trainee
Dr Tim Ho
Lismore Base Hospital (LBH) is part of the Northern Rivers Area Health
Service (NRAHS). In NRAHS, many women plan a homebirth, often from
areas such as Nimbin, Mullumbimby and Byron Bay, New South Wales.
Unemployment in this region is relatively high and there is a high
incidence of substance abuse amongst pregnant women, of teenage
pregnancy and of distrust of traditional medicine.
O and G Resident
It is difficult to ascertain exactly how many homebirths are planned
per annum. The data collection system in New South Wales
identifies only one related category, namely that of planned
homebirth. Unfortunately, this box is often not ticked in appropriate
cases.
Collection of data about homebirth attendants (for example,
midwifes and alternative birth attendants or doulas) is difficult
because not all are registered, even if they perform substantial
numbers of homebirths. A large number of doulas offer education
and emotional support, but are not required to be registered in any
way.
As data about homebirths and their outcomes was unavailable,
a retrospective review was undertaken on all known planned
homebirths that resulted in hospital transfer from January 2005 to
December 2006.
The birthing unit register was manually searched to find cases of
homebirth transfer. From the notes, the following data was obtained:
maternal age; smoking history; drinking history; distance from LBH;
reason for transfer; parity; gestational age; booking details; and
antenatal workup.
High-risk pregnancy was defined as maternal history of parity
more than five; history of postpartum haemorrhage (PPH); cardiac
or thyroid disease; significant co-morbidities; and antenatal
complications.
Antenatal complications were defined as: multiple pregnancy; Rh
negative with raised antibody titres; poor fetal growth; established
or gestational diabetes; preeclampsia/pregnancy-induced
hypertension; haemoglobin less than 100g/l at booking; and
malpresentation after 34 weeks.
A complicated previous obstetric history was defined as: previous
preterm or small infant (less than 2.5kg); previous malformed baby/
stillbirth/neonatal death; previous caesarean section; previous third
stage complications; previous abruption; previous third or fourth
degree tear; instrumental delivery; or PPH.
Findings
A total of 21 mothers who had planned a homebirth underwent
intrapartum transfer to LBH between January 2005 and December
2006. These planned homebirth mothers were mainly aged 30
to 34 years old. The majority were primigravidae and tended to
be non-smokers and non-drinkers. Of the 21 women transferred
intrapartum, most lived more than 25km from the hospital. The
majority of the women transferred had incomplete antenatal workup
(86 per cent) or no booking at all (29 per cent). Of the 21 transfers,
six patients had at least one risk factor. Upon arrival to the hospital,
nearly half of the patients had a caesarean section and a further
quarter had an operative delivery.
There were two intra/postpartum fetal deaths which are described
below.
Ms D was a G2P1 who presented at LBH with fulminating
preeclampsia. She was unsure about the date of her last menstrual
period (LMP) with potential dates spanning over two months.
Lack of fetal growth was documented by the homebirth midwife
from approximately 28 weeks of gestation, but no action was taken.
The patient had consistent symptoms of preeclampsia which she
reported to her midwife, who offered reassurance over the phone,
however, no face-to-face review was undertaken.
Ms D reported to her midwife that there had been no fetal
movements for eight days. The patient was then reviewed by the
midwife who noted that fetal heart rate was 100 beats per minute
and the patients blood pressure was 170/90. Ms D was advised
to go to hospital, however, no information was given regarding the
urgency of the situation or the advisability of having an attendant.
Ms D attended first to her own personal matters and presented to
the hospital several hours later. On arrival at LBH, she underwent
an emergency lower section caesarean section for fetal distress. Her
infant required full resuscitation and died less than four hours later.
Ms C, G4P2, presented at LBH with antepartum haemorrhage at
term. She discharged herself against medical advice less than five
hours after presentation. She continued to bleed for the next two

Table 1. Characteristics
Table 2. Transfer to hospital
Age
Distance from LBH
Total
Total
20-24
< 10km
25-29
10-25km
30-34
10
25-50km
11
35-39
> 40
Reason for transfer

during labour
Smoking
Total
Total
Failure to progress
13
1
Marijuana
Pain relief/exhaustion
No
15
Unknown
Placenta/vasa praevia/
abruption/bleed
Post induction
Prolonged rupture of
membrane
Thick meconium/fetal distress
Drinking
Total
< 2 standard
drinks/week
> 2 standard
drinks/week
Nil
13
Unknown
Parity
4
Total
14
2
Gestational
age at transfer
< 37
2
Total
1
37-41
14
42
Table 3. Antenatal care

Hospital booking
Total
No booking
Usual booking
15
Grand total
Antenatal workup
21
Total
Complete
Incomplete
18
Grand total
21
days while at home. The patient was reviewed by her homebirth

midwife at home and was reassured that the pregnancy was
satisfactory. She had spontaneous rupture of membranes two days
later, accompanied by heavy blood loss. The midwife was present
at that stage, however, no action was taken for a further four hours.
Finally, the decision was made by the midwife to transfer her to
hospital.
The patient arrived at LBH five hours later unaccompanied
by a midwife, via her family car. Intrauterine fetal demise was
subsequently diagnosed and a fresh stillborn male infant was
delivered shortly after.
Discussion
The rationale for conducting this review was that in the preceding
12 months, the second author had commenced duty at LBH and
been informed there had been twins delivered at home, with
neonatal morbidity of the second twin. Therefore the preceding twoyear timespan was systematically evaluated (excluding the patient
with twins).
It was surprising to find that most patients who had been transferred
in to LBH were unbooked or had poor booking records/antenatal
workup, so the opportunity to prevent adverse outcome had been
missed. In fact, many of the women had high-risk pregnancies but
nevertheless planned homebirth. Not surprisingly, there was a high
perinatal mortality.
It is a concern that homebirth midwives are accepting complicated
cases of twins, previous caesarean delivery and late reproductive
32 O&G Magazine
age. The practice of one midwife has been reviewed by the unit and
referred to the Australian College of Midwives and the Health Care
Complaints Commission.
In this series, we were concerned to find a remarkably high tendency
to accept high-risk cases for homebirth. Homebirth midwives may
be placed in a difficult situation by high-risk women who claim
that they refuse under any circumstances to deliver in hospital.
The reasons are varied, but include previous negative hospital
experience, a philosophical opposition to traditional birth practices
in hospital and concerns about disempowerment in the hospital
situation.
Women with a previous negative hospital experience may often
choose homebirth for their next delivery. Their negative experiences
include dissatisfaction with protocols, bad experiences with
attendants and feelings that a bad outcome might have been
preventable. Many of these women fear obstetric intervention,
particularly induction, assisted vaginal delivery and caesarean
section, which they feel are undertaken too readily and without
allowance for natural processes to prevail. A fear of orthodox
medical practices is also common. Antibiotic prophylaxis for group
B streptococcus (GBS) or treatment of intrauterine infection was
often opposed and a number of women reject the entire package.
Some women accepted interventions or medications such as
antibiotics after appropriate discussion, but many continued to
refuse therapy, often on the advice of the homebirth midwife or
doula, whose continuing involvement after transfer can create
difficulties.
It is facile to state that the incidence of intervention, regional
anaesthesia and indeed neonatal resuscitation will be low in the
homebirth setting, because they are simply not available. Many
women are not satisfied with the birth centre option and will choose
homebirth. It is clear that the RANZCOG recommendation (C-Obs
2 Home Birth) that women seeking homebirth should be counselled
regarding the significance of risks as applied to their own obstetric
condition and cared for by a medical practitioner is not occurring.
The statement that the numbers are small is relative and incorrect.
The reasons for and expectations of women choosing to birth at
home may be different in metropolitan and rural centres.
Often associated with the above is the issue of disempowerment.
This issue of empowerment is frequently advanced by homebirth
parturients and homebirth attendants as a primary goal. This issue
is often related to those above, but is frequently an issue in its
own right. It implies disenchantment with traditional practice but
is also more complex than that. It extends beyond gender in that
most hospital-based obstetric caregivers are female. Some centres
such as St George Hospital in Sydney have extended their birth
centre programs to include women who plan homebirth. It would
seem beneficial to have these patients at least partially involved
with a hospital clinic and booked at the hospital in case transfer is
necessary.
The simplistic conclusion by proponents that homebirth is safer than
hospital birth is belied by this study. Homebirthers are receiving a
considerable amount of misinformation about the safety of their
decision.
In contrast, in the Netherlands, 30 per cent of births are planned
homebirths. The community has a strong expectation that
women can give birth at home. Each woman is cared for by a
publicly-funded midwife for the entire pregnancy. All complicated
pregnancies are referred to an obstetrician. Midwives are
considered as gatekeepers and they have substantial case loads
(more than 100 per annum). They are responsible for referral to

an obstetrician if complications arise. Appropriate ambulances
are readily available in this small country. The Netherlands is rated
among the countries with best maternal and infant health statistics.1
Table 4. Significant pregnancy risk factors

Significant co-morbidity/
antenatal complication
Total
Studies have shown that planned homebirth for low-risk women

using certified professional midwives was associated with lower
rates of medical intervention, but similar intrapartum and neonatal
mortality to that of low-risk hospital births.1
No
15
Unknown
Yes
An Australian study was conducted by Flinders University of South

Australia, Perinatal death associated with planned homebirth in
Australia: population based study. They found that Fifty perinatal
deaths occurred in 7002 planned homebirths in Australia during
1985-90; 7.1 per 1000 (95 per cent confidence interval 5.2 to
9.1) according to Australian definitions and 6.4 per 1000 (4.6 to
8.3) according to World Health Organisation definitions. How
disappointing that the death rate was two in 21 (or 9.52 per cent) in
our series.
No
16
Unknown
Yes
We believe that registration is required for all homebirths so

the total picture can be audited. New South Wales Health is to
collaborate with the Australian College of Midwives to implement a
model for a homebirth program which has been proven successful
in other areas.
We recommend homebirth accreditation for all homebirth
attendants and a registration system which should be mandatory.
All homebirth midwifes should follow Australian College of Midwives
guidelines.
Acknowledgement
Poor fetal growth
Total
Diabetes
Total
No
Unknown
13
Yes
Pre-eclampsia or severe PIH
Total
No
19
Unknown
Yes
Caesarean section
Total
No
19
Yes
Birth requiring pelvic floor repair
Total
Third degree tear
No
20
We thank A/Professor Kate Moore, St George Hospital, New South Wales,

for help with preparation of this article.
Table 5. Outcome
References
Emergency caesar
10
Episiotomy
Forceps
IOL/Augmentation/ARM
Vacuum
1.
2.
3.
4.
5.
7.
http://www.birthingthefuture.com/AllAboutBirth/hollandslesson.php .
http://www.expatica.com/actual/article.asp?subchannel_id=7&story_
id=997 .
http://www.homebirthaustralia.org/homebirth.html .
Bastian H, Keirse M, Lancaster P. Perinatal death associated with
planned home birth in Australia: population-based study. BMJ 1998;
317:384-388 (8 August).
http://www.pregnancy.com.au/homebirth1.htm .
http://www.siliconforest.com.au/employment.html .
Intervention
Intrapartum and neonatal

mortality
Total
Total
No
19
Yes
Second Hand books wanted for PNG

The College has received a request from Nonga, Rabaul, Papua New Guinea, for some core O and G textbooks for its
hospital library. We are hoping to obtain previously loved (but not too old) copies of:
Dewhursts Textbook of Obstetrics and Gynecology, EDMONDS D
Williams Obstetrics, CUNNINGHAM GARY
Obstetrics by Ten Teachers, BAKER PHILIP
Llewellyn-Jones Fundamentals of Obstetrics and Gynaecology, OATS JEREMY
Obstetrics and the Newborn, BEISCHER NORMAN
Other medical texts (relevant to primary healthcare) will be gladly accepted.
Please email Carmel Walker (cwalker@ranzcog.edu.au) if you have suitable books you can send to College House
(preferably no older than ten years).
A midwifes perspective on
homebirth in New Zealand
Homebirthing is a contentious issue for some in the maternity services, as is
evidenced by the use of descriptors such as risky, unsafe and scary.
Cheryl Benn
Lead Maternity Carer

Registered Midwife
However, for many women,

(primigravidas, multigravidas and
midwives), their experience of
homebirth is one of safety, satisfaction
and a real sense of being in control
and empowered by their birth
experience in an environment of their
choosing, while being supported
by family and friends that they have
chosen to have with them at that time.
There is a recent body of international

literature that compares home and
hospital birth outcomes for lowrisk women cared for by midwives or physicians. The Dutch study
by de Jonge et al 1 indicates that risks of perinatal mortality and
severe morbidity are not increased provided there are well-trained
midwives and a good transportation and referral system. Janssen
et al 2, in a Canadian study comparing outcomes of planned
homebirth with registered midwives with planned hospital birth
for women cared for by a midwife or physician, found that the
perinatal death rates were very low and that there were reduced
obstetric interventions. Preliminary findings from a more recent, as
yet unpublished, large New Zealand retrospective cohort study of
16,000 low-risk women cared for by lead maternity carer (LMC)
midwives show that place of birth has a significant and dramatic
effect on emergency caesarean section rates (Birthplace New
Zealand Research Group, unpublished data). Low-risk women cared
for by an LMC midwife and birthing in a tertiary level hospital are six
times more likely to a have an emergency caesarean section than
those cared for by an LMC midwife in a primary unit. Those birthing
in a secondary level unit are three times more likely to have an
emergency caesarean section.
In this article, I present a case of a primigravid woman, who was
initially diagnosed with a bicornuate uterus, who chose to have
a homebirth. I will use this case to illustrate the systems that were
utilised to support her choice of place of birth.
The homebirth experience of one woman
This woman was a PhD student when she unexpectedly fell pregnant
for the first time, despite having an intrauterine device in situ. This
was not part of her life plan at this stage but she went for an early
scan (at approximately six weeks gestation) to check if she was
pregnant. Two issues were identified: her IUD was not suitably sited,
hence the unexpected pregnancy, and she had a bicornuate uterus
with the pregnancy in the left horn. Her first action was to have the
IUD removed and then, with no resulting after effects, she decided
to find an LMC midwife and discuss the issue of the bicornuate
uterus.
The woman was referred to an obstetrician for a consultation
shortly after she registered with an LMC. The LMC attended the
visit to ensure she also understood the information provided, to
34 O&G Magazine
assist the woman in making the decisions she was faced with,
given the complexities of her life at the time of this unexpected
pregnancy. Her mother was visiting from Australia and attended
the visit as well. The consultation occurred at nine to ten weeks
gestation followed by a scan which confirmed fetal viability, but
the bicornuate appearance was stated to be no longer obvious
and the cervical length was normal. The woman was informed
that, with a bicornuate uterus, she had the following risks: cervical
incompetence; preterm labour; preterm rupture of membranes;
malpresentation; and dysfunctional labour. A plan was put in
place which included a possible cervical suture if the cervix was
shorter than 2.5cm in length and the need for repeat scans to
check cervical length and growth of the baby. The latter scans were
recommended for 28, 32 and 26 weeks gestation. It was also
agreed that the LMC would remain, providing care for the woman
in conjunction with the obstetrician. The womans pregnancy
progressed uneventfully and she had the recommended scans until
32 weeks gestation, at which stage she stated that she felt no need
for further scans, as all had progressed accordingly and the baby
had grown well.
Low-risk women cared for by an

LMC midwife and birthing in a
tertiary level hospital are six times
more likely to a have an emergency
caesarean section than those cared
for by an LMC midwife in a primary
unit.
The issue of place of birth had been discussed on and off during
her pregnancy, but decisions were put on hold as there was a need
to ensure that her chosen place of birth was appropriate for her
situation. The woman had good friends who had a homebirth with
their first pregnancy, so she was strongly drawn to it as an option.
She read widely on place of birth, as well as regarding her specific
challenges. Having weighed up all the options, considering she had
not developed any further challenges in relation to her pregnancy
and that her baby was well-grown, she opted for a homebirth.
Her expected date of birth was 26 April based on the five to sixweek scan. At 41 weeks, she commenced spontaneous labour.
She laboured at home supported by her mother and homebirthing
friends and called her midwife when the contractions were frequent
and strong. Soon after her midwifes arrival, she had a spontaneous
rupture of membranes (SRM) with clear liquor draining and
verbalised feeling pressure in her bowel and back. Shortly after
the SRM, she got into the birthing pool and found she relaxed well
and felt more comfortable in the pool. Her babys heart rate was

auscultated frequently and the temperature of the room and the
pool water were checked frequently. About four to six hours later,
she felt she could not keep going. A vaginal examination was
performed and her cervix was found to be 7cm dilated, fully effaced
with the head at station 0, with the posterior fontanelle directly
under the symphysis pubis and no membranes felt. This finding
encouraged her that she had made good progress. Half an hour
later, she felt like having a bowel motion and, despite the fear she
felt, she was being well-supported by her birth team. She was eating
and drinking and resting well between the contractions. An hour
and a half later, she felt an urge to push with a contraction and her
cervix was found to be fully dilated. As the contractions continued
and her urge to bear down increased, the woman, with the help of
her birth team, pushed past her fear and birthed her 3800g baby
one hour and 13 minutes after full dilatation was confirmed. After
stimulation and drying, the baby cried spontaneously by one minute
after birth and required no further resuscitation.
The placenta and membranes were born physiologically less than
one hour later, with an estimated blood loss of 250ml and a second
degree tear of the perineum, which was well aligned and not
bleeding. The woman declined suturing and was educated about
perineal care and what to report concerning her own health and
that of her baby. The woman and her babys postnatal period were
uneventful. She was still exclusively breastfeeding at the time of
discharge and after frequent discussions about her labour and birth,
she and her mother wrote the following letter which they have been
happy to have published in any appropriate forum.
Homebirth why not?

Eleven months ago, my youngest daughter, who lives in regional
New Zealand, announced that she was considering a water birth
at home for her first baby. I received this news at my home in
Sydney with some trepidation. As a registered nurse (though my
area of expertise is far from maternity), my mind immediately
analysed clinical risk, possible outcomes for daughter and
baby and likelihood of transfer to hospital once labour had
commenced. My own obstetric history (hospital birth with multiple
medical interventions on both occasions) added to the sense of
discomfort.
The continuity of service was outstanding:

clinical explanation and options were readily
forthcoming, response to ad hoc queries were
prompt, emotional support was warm but
never invasive.
My fears evaporated on meeting the midwife who was to be
with my daughter throughout the pregnancy and the six-week
postnatal period. I became intrigued by the decision and
celebrated the normality associated with it.
I followed the antenatal visits very closely, all of which took place
at home. From the first appointment (at around eight weeks), the
continuity of service was outstanding: clinical explanation and
options were readily forthcoming, response to ad hoc queries
were prompt, emotional support was warm but never invasive.
Initially, there was a specific requirement for medical opinion via
the high-risk antenatal clinic at the local hospital. The midwife
acted as an advocate with the medical staff at the hospital, which
resulted in an excellent working partnership rather than a standoff!
The minor health problems that often occur in pregnancy were

never brushed aside, but explanation offered and options and
solutions suggested in a consultative process with my daughter.
The birth plan was commenced well in advance to allow time
for adjustment and discussion. Two delightful midwifery students
joined the team and only added to the sense of expertise
available.
I felt privileged to be part of the team present at my
granddaughters water birth at home as planned, with friends
(which includes the midwives) present in a warm, loving
environment.
My nervousness was offset by my well-placed confidence in the
midwives and my daughter, who knew exactly what they were
doing and were equally keen for the very best outcome for all of
us. I asked questions when I was unsure, knowing the answers
would be honest and based on clinical expertise and experience.
During labour, when pain or tiredness was evident, discussion
between my daughter and midwives ensured positive steps were
taken to alleviate the discomfort. While my daughters request
for as little intervention as possible was supported, there was
open dialogue to ensure the babys wellbeing.
As a long-time RN, I have witnessed an enormous range
in levels of professionalism, skill and care in health systems
internationally. We my daughter, granddaughter and myself
have been privileged to experience some of the best Ive
encountered.
Systems available to support womens choice of
homebirth
In New Zealand, registered midwives practice autonomously and
can choose to birth women in any setting available to them and for
which they have an access agreement, for example, at home, in
a primary birthing unit, or in a secondary or tertiary-level hospital.
Midwives are required to give women information about the options
available in their area to assist them to make an informed decision.
The choice is driven by the woman rather than the midwife,
however, the midwife guides the woman depending on the health of
the woman and her baby. The choice of place of birth is not fixed,
but may change at any time during the pregnancy, labour and birth
process.
The requirements of lead maternity carers are spelled out in the
Notice Pursuant to Section 88 of the New Zealand Public Health
and Disability Act 2000, which have appended to them guidelines
for consultation with obstetric and related specialist medical
services. There are three levels of referral which emphasise the need
for a three-way consultation between the woman, the specialist
and the lead maternity carer. In the case of the woman discussed
earlier, the three-way consultation resulted in a plan of care which
she agreed to, but then made some unilateral decisions when
she deemed further assessments were not required. She always
understood that the decision about place of birth was fluid, but was
committed to birthing where she was comfortable, as long as she
was informed if any deviations from the normal warranted a transfer
to the local secondary care hospital.
Present at the birth was her mother, friends, a student midwife who
was placed with the lead maternity carer and a back-up midwife. A
back-up midwife is always invited to be present at a homebirth to
ensure that an extra set of hands is available if required. The LMCs
in some districts also provide the woman with linen for the
birth, some of which is used to protect the beds and carpets, with all
soiled linen and garbage removed at the end of the birth.
Intrapartum fetal
monitoring
Yesterday, today and tomorrow
Dr Wan Tinn Teh
RANZCOG Trainee
Dr Stephen Tong
FRANZCOG
During labour, the uterine contractions needed to expel the baby induce
complete blood flow arrest, the consequence being progressive fetal hypoxia.
The challenge for obstetricians is to find the balance between safe and timely
delivery of the baby before irrevocable damage occurs and overly aggressive
interventions to effect delivery.
Currently, intrapartum fetal monitoring is based on interpretation of

the fetal cardiovascular response to stressors, where the obstetrician
needs to judge whether the heart rate patterns could be consistent
with a compromised fetus.
Traditional methods
Cardiotocograph
The most commonly used modality to monitor the fetus during
labour is electronic fetal heart rate monitoring via cardiotocograph
(CTG). CTG has a sensitivity of 85 per cent with a corresponding
high negative predictive value in predicting the absence of fetal
hypoxia, but is only 40 to 50 per cent specific with a poor predictive
value.1 While reassuring CTG patterns are reliable predictors of
fetal wellbeing, the CTG is poor in accurately identifying fetal
hypoxia. Non-reassuring CTG patterns are seen commonly in
fetuses that are normoxic and entirely healthy. It has been shown
that the use of routine CTG has only a minor beneficial effect on the
incidence of neonatal seizures, but increases the number of assisted
deliveries.2 The main reason for the continued use of CTG is the
lack of a better way to identify hypoxic fetuses in labour.
Fetal scalp sampling
Fetal scalp sampling was first described by Sailing in 1964.1 By
measuring the pH or lactate of blood obtained from fetal scalp
capillaries, we can directly evaluate the fetus for acidosis. However,
it requires invasive sampling of fetal blood by puncturing of the
fetal scalp. Besides causing significant discomfort to the woman,
the sample can also be technically difficult to acquire. Therefore, it
can be difficult to perform serially on the same woman if the CTG
continues to be non-reassuring.
Evolving modalities
Fetal pulse oximetry
Fetal pulse oximetry (FPO) is a relatively new technology. A sensor
using far- and near-infrared wavelengths is placed transvaginally
to measure oxygen saturation in the fetus. In contrast to fetal scalp
sampling, this technology allows continuous monitoring of fetal
oxygenation. The other proposed benefit of FPO is that it might
improve the specificity of intrapartum surveillance. However, its
clinical efficacy in reducing unnecessary operative deliveries is yet to
be proven.3
Fetal electrocardiography
An alternative method of evaluating the fetus oxygenation status
36 O&G Magazine
during labour is to use the electrical signal emitted during the

fetal cardiac contraction cycle and analyse its components. The
ST segment waveform of the fetal ECG provides continuous
information on the ability of the fetal heart muscle to respond to
the stress of labour. Additional use of ST analysis of the fetal ECG
has been shown to improve the specificity and positive predictive
value of intrapartum CTG monitoring.4 However, it has also been
recognised that some fetuses may not display ST changes on an
ECG despite their hypoxic status, either because monitoring started
after ST changes took place or because, for unknown reasons, the
fetus simply does not display identifiable ST changes.5
Future technology
Dynamic transcriptional profiling of fetal hypoxic gene
Prevention of intrapartum hypoxic stress to the fetus so as to improve
neonatal morbidity and mortality is an ongoing research aim for
the obstetric community, as an improved, non-invasive test could
substantially decrease the intervention rate.
It was recently reported that ribonucleic acid (RNA) of fetal origin
circulates in the maternal blood and disappears around 15 minutes
after delivery. This suggests that RNA from the placenta is released
in a steady state. The implications are significant. It may be possible
to develop a maternal blood test, measuring for the presence
of hypoxic genes that directly suggest that the placenta is in fact
deprived of oxygen and the fetus is in jeopardy. It could provide
additional evidence to interpret, along with CTG findings, that
would increase the clinicians ability to accurately determine which
fetuses are truly hypoxic.
Hypoxia in any tissue is tightly regulated by a master regulator,
the hypoxia inducible factor (HIF). When HIF is released, it binds
to promoter sites and up-regulates a suite of genes to initiate a
hypoxic response. Such genes include enzymes involved in the
glycolytic pathway, induction of erythropoietin (to increased red cell
production), induction of vascular endothelial growth factor, and
vasodilators such as nitric oxide.7 To date, nearly 100 genes have
been identified that are regulated by HIF and any of these could, in
theory, be measured by a fetal distress blood test.
A longitudinal cohort study is being performed at Monash Medical
Centre, Clayton, to examine whether RNA coding hypoxic regulated
genes obtained from maternal blood could be used to noninvasively identify which babies are already genuinely distressed
from hypoxia, or to predict which ones will become distressed soon.

We are recruiting pregnant nulliparous women with a singleton
pregnancy, who are having induction of labour. Maternal blood
samples are being collected from these women throughout their
labour via a second IV cannulae. Timepoints of interest are: just
before induction (no hypoxic genes should be present as there have
been no uterine contractions); one sample during active labour;
and a final sample at the moment of delivery (a number will be
hypoxic). Whether the baby was in fact hypoxic will be determined
by umbilical cord lactate levels measured immediately after delivery.
RNA molecules are being isolated from these samples in the
laboratory. We are using PCR-based platforms that specifically
measure genes belonging to the hypoxia pathway. The results are
being analysed in conjunction with other information collected,
including CTG findings, fetal scalp sampling results if performed,
apgar scores at birth and cord lactate results. Preliminary results
have been promising, showing that multiple hypoxic genes are
increased in expression in cases where fetal distress occurred, but
are not increased in the control group.
The ultimate goal of our study is to develop a minimally invasive
novel bedside test in delivery suite that better reflects hypoxic
status in fetuses than the CTG. Such a test will allow us to reserve
operative delivery for fetuses that truly need it and decrease the
intervention rates for women.
A midwifes perspective on homebirth in New Zealand continued from

page 35.
In addition, oxytocics are stored in the fridge, either before the

labour commences or when the LMC arrives, to ensure that it is
available for active management of the third stage if required or
for treatment in the case of a postpartum haemorrhage. A birth
pack and resuscitation equipment for the mother and the baby
are part of the homebirth kit.
In addition to all the equipment, homebirth midwives maintain
their knowledge of dealing with unexpected emergencies,
such as shoulder dystocia, breech birth (unplanned), neonatal
resuscitation, postpartum haemorrhage and cord prolapse.
Awareness of ambulance calls and who might be needed for
support is also vital when planning a homebirth, as well as good
preparation of the family.
Conclusion
Homebirth is different from hospital birth. As stated by Justine
Caines from Homebirth Australia, Women make decisions about
their care. They invite a midwife into their home, rather than be
forced to meet the needs of practitioners and organisational
convenience, which happens when giving birth in a hospital.
The people to consult about homebirth are the women and the
midwives who work with them.
References
1.
2.
3.
4.
5.
6.
7.
Schwartz N, et al. Intrapartum fetal monitoring today. Journal of

Perinatal Medicine 2006; 34:99-107.
Thacker SB, Stroup D, Chang M. Continuous electronic heart rate
monitoring for fetal assessment during labor. Cochrane Database of
Systematic Review 2001; (2):CD000063.
East CE, Chan FY, Colditz PB, Begg L. Fetal pulse oximetry for fetal
assessment in labour. Cochrane Database of Systematic Reviews
2007; 2:CD004075.
Neilson JP. Fetal electrocardiogram (ECG) for fetal monitoring
during labour. Cochrane Database of Systematic Reviews 2006;
3:CD000116.
Rosen KG. Fetal electrocardiogram waveform analysis in labour.
Current Opinion in Obstetrics and Gynecology 2005; 17:147-50.
Ng EK, Tsui NBY, Lau TK, Leung TN, Chiu RWK, Panesar NS, et al.
mRNA of placental origin is readily detectable in maternal plasma.
Proceedings of the National Academy of Sciences
2003;100(8):4748-53.
Schumacker PT. Hypoxia-inducible factor-I. Critical Care Medicine
2005; 33(12):S423-5.
References
1.
2.
3.
De Jonge A, van der Goes BY, Ravelli ACJ, Amelink-Verburg MP,

Mol BW, Nijhuis JG, Bennebroek Gravenhorst J, Buitendijk SE.
Perinatal mortality and morbidity in a nationwide cohort of 529
688 low-risk planned home and hospital births. BJOG 2009; 116,
1177-1184.
Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK.
Outcomes of planned home birth with registered midwife versus
planned hospital birth with midwife or physician. CMAJ 2009;
September 15, 181(6-7), 377-383.
Primary Maternity Services Notice 2007. Notice pursuant to Section
88 of the New Zealand Public Health and Disability Act 2000.
Supplement to New Zealand Gazette, 41.
Medical pamphlets
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Controlling the timing

of labour
The role of progesterone and
prostaglandins
Preterm birth is the leading cause of perinatal mortality and morbidities in
developed countries, including Australia, with inadequate treatment options for
the prevention or treatment of preterm labour.
Labour and delivery require an
intricate series of coordinated
events that are poorly understood
in women. Our lack of knowledge
of the mechanisms that control
the transition from a quiescent to
a contractile uterine phenotype
impedes the development of novel
therapeutics for preventing preterm
Dr Toni Welsh
labour and reducing preterm birth
Mothers and Babies
rates. The World Health Organisation
Research Centre
University of Newcastle
(WHO) estimates that preterm births
(less than 37 completed weeks of
gestation) comprise 9.6 per cent
of all worldwide births, which equates to 12.9 million babies
delivered preterm each year.1 While approximately one third of
preterm deliveries are indicated for maternal or fetal complications,
the remaining two thirds of spontaneous preterm births that result
from spontaneous preterm labour and premature preterm rupture
of membranes (PPROM) are candidates for interventions that will
prevent or stop preterm labour.2
Our studies at the Mothers and Babies Research Centre in
Newcastle, New South Wales, investigate the regulation of uterine
contractility and hormonal interactions that determine the timing
of labour onset in women. I received the Ella Macknight Memorial
Scholarship from the RANZCOG Research Foundation for 20092010 to pursue the role of two key hormones, progesterone and
prostaglandins (PGs), in modulating uterine contractility in pregnant
women. By better defining the actions of these hormones at a
molecular level in the pregnant uterus, we expect to identify much
needed new therapeutic targets for the prevention of preterm birth.
Mechanisms of progesterone action and functional
progesterone withdrawal
The role of progesterone in suppressing uterine contractility is
common to all mammals. Progesterone withdrawal is a crucial
event that precedes the onset of labour and is mediated in most
species by a decline in systemic progesterone levels, leading to a
rise in uterotonin production and labour onset. In women, where
parturition is not preceded by changes in circulating progesterone
concentrations, there is thought to be a decrease in progesterone
responsiveness in the uterus. This loss of responsiveness or
functional progesterone withdrawal leads to increased production
of prostaglandins (PGs) that stimulate uterine contractions, cervical
softening and fetal membrane rupture. The mechanisms that bring
38 O&G Magazine
about functional progesterone withdrawal and the parallel increase

in PG synthesis in women are largely unknown.
A clear understanding of how progesterone relaxes the pregnant
uterus and how its actions are controlled is important, because
recent clinical studies have indicated that progestin-based
therapeutics reduce the risk of preterm birth when administered
prophylactically in women at risk of recurrent preterm labour.3,4
The benefit of progestin-based therapies is apparent in singleton
pregnancies but not in twin or triplet pregnancies, and is not
necessarily associated with a decrease in perinatal deaths or
improved neonatal outcome. Therapies based on progestin
supplementation are not useful for acute tocolysis in women
presenting in preterm labour and it is unclear how they exert their
benefit considering the already saturating levels of endogenous
progesterone present during pregnancy. A greater understanding
of the mechanisms of action of progesterone and progesterone
receptors (PRs) in the uterus may lead to more targeted methods
of maintaining progesterone function as secondary or tertiary
inventions for the prevention of preterm labour and preterm birth.
Recent research has advanced our understanding of the molecular
mechanisms of progesterone withdrawal in women and introduced
novel pathways for the suppression of uterine contractility.
Several molecular mechanisms may contribute to functional
progesterone withdrawal in the myometrium, including changes in
PR isoform expression, changes in PR co-regulator expression and
reduced binding of PRs to gene promoters. We have previously
shown that advancing gestation and labour onset are associated
with changes in PR isoform expression in women. The B receptor
isoform is the dominant mediator of progesterone actions, whereas
the A isoform suppresses the actions of PR-B, therefore an increase
in the PR-A to PR-B ratio reduces progesterone responsiveness.
A critical change in the expression of PR isoforms occurs prior to
labour onset in women that results in an increase in the PR-A to PR-B
ratio in the uterus.5 Similar results have been reported in the rhesus
monkey, indicating that an increasing uterine PR-A to PR-B ratio
may be a common pathway for functional progesterone withdrawal
in primates. PRs function by controlling gene transcription in target
cells, in concert with various steroid receptor co-regulator proteins
that can increase or decrease the transcriptional activity of the
receptor. The expression of PR co-activators decreases in human
and mouse uteri at term and with labour onset.6 Thus, the changing
PR-A/PR-B ratio in the uterus at term is accompanied by alterations
in PR co-activator expression that likely further reduce progesterone
responsiveness.

Several nuclear receptor co-activators possess histone acetylase
activity and regulate PR activity via chromatin remodelling.
Acetylation of histones, the protein component of chromatin, creates
an open chromatin conformation in which transcription factors
are able to access gene promoters and regulate gene transcription;
histone acetylation therefore enhances the transcriptional activity of
PRs. Histone deacetylase (HDAC) enzymes conversely generate a
closed chromatin conformation and reduce PR activity. The levels
of histone acetylation decrease in the human and mouse uterus
during labour6, which would promote progesterone withdrawal.
Maintaining histone acetylation, and therefore progesterone activity,
is an attractive target for novel tocolytic development. The HDAC
inhibitor Trichostatin A (TSA) up-regulates PR-B expression in uterine
cells7, inhibits contractions in human uterine tissue in vitro8 and
delays parturition in mice.6 HDAC inhibitors also suppress COX-2
expression in human myometrial cells9 and may therefore prolong
pregnancy by increasing progesterone responsiveness and reducing
intrauterine PG synthesis. There is clear potential for the use of
HDAC inhibitors as tocolytic agents and the effect of these inhibitors
on myometrial function is a major focus of our research funded by
the RANZCOG Research Foundation.
Feed-forward interaction between progesterone and
prostaglandins at labour
PG production increases in the uterus before and during labour as a
consequence of the up-regulation of the key inducible PG-synthetic
enzyme, COX-2. While inhibitors of PG synthesis have been trialled
and used extensively for the treatment of preterm labour, adverse
neonatal outcomes such as patent ductus arteriosus and impaired
renal function have limited their usefulness as tocolytic agents. The
interaction between progesterone and PGs in the pregnant uterus
is poorly understood, although progesterone is known to suppress
PG production until shortly before the onset of labour. Support for
a role of PGs in triggering progesterone withdrawal in women first
came from studies by our group which showed that PGs caused an
increase in the PR-A/PR-B ratio in myometrial cells10, and similar
results have been reported in decidual cells. The resultant increase
in the PR-A/PR-B ratio would reduce progesterone responsiveness
and increase uterine activity. These findings support the concept of a
feed-forward interaction between PGs and progesterone withdrawal
in the pregnant uterus. We propose that PGs stimulate a decrease
in myometrial progesterone responsiveness, and that progesterone
withdrawal in the myometrium leads to rising intrauterine PG
production, resulting in a feed-forward mechanism that increases
uterine activity and leads to labour onset. Defining the early events
that catalyse the activation of this pathway may provide crucial
knowledge of the mechanisms that initiate labour onset in women.
Conclusions
Birth at an early gestational age is a leading contributor to perinatal
mortality and morbidities, including acute morbidities such as
respiratory distress syndrome and necrotising enterocolitis, as well
as long-term morbidities such as cerebral palsy, blindness and
hearing loss. Investigating the molecular mechanisms by which
progesterone suppresses contractility in myometrial smooth muscle,
and the coordination of progesterone and prostaglandin signalling
in the pregnant uterus, is an important field of active research, with
potential for the development of targets for novel therapeutics that
will maintain uterine quiescence and prevent spontaneous preterm
labour and preterm birth and reduce adverse neonatal outcomes.
With generous support from the RANZCOG Research Foundation,
I will be able to make progress towards these goals during the
upcoming years.
References
1.
Beck S, Wojdyla D, Say L, Betran AP, Merialdi M, Requejo JH, Rubens

C, Menon R, Van Look PFA. The worldwide incidence of preterm birth:
a WHO systematic review of maternal mortality and morbidity. Bull
World Health Organ. 2009; 88:doi:10.2471/BLT.08.062554.
2. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and
causes of preterm birth. The Lancet 2008; 371(9606):7584.
3. Dodd JM, Flenady VJ, Cincotta R, Crowther CA. Progesterone for
the prevention of preterm birth: a systematic review. Obstet Gynecol.
2008;112(1):127-34.
4. Calda P. Safety signals of 17-OHP-C use in pregnancy and efficacy in
the prevention of preterm birth. J Matern Fetal Neonatal Med. 2009;
22(6):540-42.
5. Merlino AA, Welsh TN, Tan H, Yi LJ, Cannon V, Mercer BM, Mesiano S.
Nuclear progesterone receptors in the human pregnancy myometrium:
evidence that parturition involves functional progesterone withdrawal
mediated by increased expression of progesterone receptor-A. J Clin
Endocrinol Metab. 2007; 92(5):1927-33.
6. Condon JC, Jeyasuria P, Faust JM, Wilson JW, Mendelson CR. A
decline in the levels of progesterone receptor coactivators in the
pregnant uterus at term may antagonise progesterone receptor
function and contribute to the initiation of parturition. Proc Natl Acad
Sci USA 2003;100(16):9518-23.
7. Xiong Y, Dowdy SC, Gonzalez Bosquet J, Zhao Y, Eberhardt
NL, Podratz KC, Jiang SW. Epigenetic-mediated upregulation of
progesterone receptor B gene in endometrial cancer cell lines.
Gynecol Oncol. 2005; 99(1):135-41.
8. Moynihan AT, Hehir MP, Sharkey AM, Robson SC, Europe-Finner GN,
Morrison JJ. Histone deacetylase inhibitors and a functional potent
inhibitory effect on human uterine contractility. Am J Obstet Gynecol.
2008;199(2):167.e1-167.e7.
9. Tyson-Capper AJ, Cork DM, Wesley E, Shiells EA, Loughney AD.
Characterization of cellular retinoid-binding proteins in human
myometrium during pregnancy. Mol Hum Reprod. 2006;12(11):695701.
10. Madsen G, Zakar T, Ku CY, Sanborn BM, Smith R, Mesiano S.
Prostaglandins differentially modulate progesterone receptor-A and
-B expression in human myometrial cells: evidence for prostaglandininduced functional progesterone withdrawal. J Clin Endocrinol Metab.
2004; 89(2):1010-3.
The Specialist Obstetrician Locum Scheme is

funded by the Australian Government.
SOLS provides locums for Fellows and
GP Obstetricians in rural Australia.
Further information can be obtained from the
SOLS website:
www.ranzcog.edu.au/sols/index.shtml
SOLS Project Coordinators:
tel: +61 3 9412 2912
fax: +61 3 9415 9306
sols@ranzcog.edu.au
Womens Health: Obstetric Management Update
Swine flu in obstetrics

Dr Wade Stedman
Registrar
Intensive Care Medicine
Dr Heike Koelzow
Staff Specialist
Intensive Care
Royal Prince Alfred

Hospital
Sydney
On 11 June 2009, the World Health Organisation raised the pandemic alert level
to phase six (the highest), indicating that at least two continents had widespread
community transmission of pandemic H1N1 influenza (swine flu).1
The second recorded death from
pandemic H1N1 influenza in the
Unites States was in a previously
healthy pregnant woman2 which
raised alarm bells for obstetricians.
Although most cases of the current

pandemic H1N1 influenza are mild
and self-limiting, complications can
be severe and seem to occur more frequently in some populations.
Common risk factors include chronic airways disease, pregnancy,
cardiac disease, immunosuppressive conditions, diabetes mellitus
and obesity.
Case One
A 21-year-old female presented five weeks postpartum (complicated
by postpartum haemorrhage), to a peripheral hospital with
fevers, myalgia, dry cough and shortness of breath. A chest x-ray
showed patchy bilateral infiltrates. The patient was commenced
on antibiotics and transferred to a regional centre for ongoing
care. Her respiratory function deteriorated and she was admitted
to ICU for non-invasive ventilation, where she was commenced on
oseltamivir (Tamiflu) and broad spectrum antibiotics. Despite this,
she required intubation the following day and proved increasingly
difficult to oxygenate and ventilate. On day six, she was referred to
our metropolitan hospital for retrieval on, and treatment with extracorporeal membrane oxygenation (ECMO). Figure 1 shows her
arrival chest x-ray. ECMO uses cardiopulmonary bypass technology
to provide gas exchange and has recently been used for patients
with inadequate oxygenation and/or ventilation despite maximal
mechanical ventilatory support. H1N1 pneumonia was diagnosed
and the patient required seven days of ECMO support. After a
prolonged respiratory wean, she was fit for ICU discharge after
Figure 1. CXR on arrival. ECMO return cannula (oxygenated blood) noted in

inferior vena cava.
40 O&G Magazine
13 days. She was transferred back to the peripheral hospital to be

closer to family and her baby.
Case Two
A 22-year-old woman, 14 weeks pregnant, presented to hospital
with fever, vomiting and poor oral intake for four days, where she
was diagnosed with hyperemesis and a viral upper respiratory tract
infection. Two days later she became increasingly tachypnoeic and
hypoxic with a chest x-ray showing patchy bilateral consolidation.
Nasal swabs were positive for H1N1 confirming the diagnosis
of H1N1 pneumonia. She was commenced on oseltamivir and
broad spectrum antibiotics. Despite this, she deteriorated and
was intubated that day for hypoxia and respiratory distress.
Transabdominal ultrasound on day 11 showed a viable fetus.
She deteriorated further on day 12 with increasing hypoxia and
hypercapnia, probably due to bacterial superinfection, and was
referred to our metropolitan hospital for ECMO retrieval and
support. She received three days of ECMO and was extubated on
day 20 of her hospital stay (18 days intubated). Ultrasound on day
22 revealed a viable fetus within limits for 16 weeks gestation. She
was transferred back to the original hospital on day 25.
Transmission
The influenza virus is transmitted from person to person by virus
containing respiratory secretions by coughing, sneezing or on
the hands of people who have pandemic H1N1 influenza.3
Other bodily secretions (for example, diarrhoea) should also be
considered infectious. Transmission via contact with surfaces that
have been contaminated by respiratory droplets is possible, but not
proven.4
Incubation and infectivity
While the maximal incubation period could be seven days, a
median incubation period of three to four days seems typical.5
The duration of virus shedding is from one day before illness
until resolution of the fever. This is usually three to five days, but
individuals should be considered contagious until at least seven
days after onset of illness. Children, elderly, patients with chronic
illness or immunocompromised hosts may shed the virus for weeks.
Clinical presentation
Patients with pandemic H1N1 influenza can present with any
combination of fever, rigors, cough, rhinorrhoea, sore throat,
headache, shortness of breath, myalgia and arthralgia. In addition,
vomiting and diarrhoea have been unusually common with this
pandemic. Pregnant women with pandemic H1N1 are more likely
to report shortness of breath compared with non-pregnant women
and the general population.6 However, up to 70 per cent of women
experience a sensation of dyspnoea at some stage during their
pregnancy.7 Compared to physiological dyspnoea of pregnancy, the
onset of influenza is more acute, associated with a fever and cough
and can occur at any gestation. Most cases during the current
H1N1 pandemic have been mild to moderate and most pregnant
women will have a typical course of uncomplicated influenza.
The above case reports illustrate complications of H1N1 infection.
The first case, an example of rapidly progressive viral pneumonia,
and the second case, an example of secondary bacterial
Obstetric Management Update: Womens Health

pneumonia. In both cases, the complications lead to severe
respiratory failure and adult respiratory distress syndrome (ARDS).
H1N1 in pregnancy
Influenza in pregnant women is usually a mild to moderate disease,
but pregnant women have been shown to have an increased risk of
complications and death during previous (1918-1919 and 19571958)8 and the current influenza pandemics, when compared
with non-pregnant women of a similar age. Increased rates of
spontaneous abortions and preterm birth have been reported,
especially in women with pneumonia. The Centers for Disease
Control and Prevention in the United States reported six deaths
in previously healthy pregnant women between 15 April and 16
June 2009; all had developed pneumonia and ARDS requiring
mechanical ventilation.6 Recent figures from Australia and New
Zealand found that of 722 patients with confirmed H1N1 influenza
admitted to an ICU, 66 (9.1 per cent) were pregnant.9 Exact data
on incidence of H1N1 pneumonia and rate of complications in
pregnant women are still under investigation at this time.
Diagnosis
An influenza-like illness (ILI) is defined as a history of a fever (or
temperature greater than or equal to 38.0C), and either a cough
and/or sore throat. A confirmed case of H1N1 influenza is the
combination of an ILI and laboratory confirmed H1N1 influenza
A detection by specific polymerase chain reaction (PCR), viral
sequencing or virus culture.
Where diagnosis is made on clinical grounds, New South Wales
Health guidelines do not recommend laboratory testing, except
where it will change clinical management, or a woman requires
hospital admission.5
Testing for H1N1
Both nasal and throat specimens are required for testing. Local
health authorities have clear guidelines regarding the procedure
for correct specimen collection when testing for H1N1, which we
encourage you to review. However, even correct technique can
lead to false negatives. In our experience, even with severe H1N1
infections with presumed high viral loads, we have had some
cases with false negative swab results but positive results with
bronchoalveolar lavage.
Doctors should not delay treatment

while awaiting test results.
Treatment
The current pandemic H1N1 influenza virus is sensitive to
neuraminidase inhibitors oseltamivir and zanamivir. There is good
evidence that these drugs, if started within 48 hours of the onset of
illness, reduce the severity of seasonal influenza.10 A recent series of
studies on H1N1 in pregnancy published in The Lancet found that
in the patients who died, none had commenced treatment within 48
hours.6 However, commencing oseltamivir more than 48 hours after
symptom onset is still likely to reduce mortality.11
Treatment with oseltamivir or zanamivir can be offered at any
stage of pregnancy and should not be delayed in patients with
an influenza-like illness while awaiting test results. Both drugs are
currently classified B1 (limited data indicating safety in pregnancy),
but use to date (mostly in the second and third trimester) has not
been associated with adverse outcomes. The risks of a complication
from H1N1 appear to outweigh the risks of treatment especially in
the second and third trimester and around the time of birth. New
South Wales Health guidelines strongly recommend treatment to
reduce the severity of the disease in the mother.4,5 At all stages,

it is important to give symptomatic treatment for fever, such as
paracetamol, as maternal hyperthermia during the first trimester can
double the risk of neural tube defects and may be associated with
other adverse outcomes.12,13
The benefits of treatment with

appropriate antivirals appear to
outweigh the risks, especially in the
second and third trimester, and are
more effective when commenced
within 48 hours of illness.
Prevention and immunisation
The best prevention is with the newly approved (18 September
2009) CSL pandemic influenza vaccine. The human adult trials
have indicated that the pandemic vaccine is similar to that of
seasonal influenza vaccine, with a high safety and low adverse
events profile, and that only one injection is required for adults.14
Other simple precautions include:
Wash hands regularly.
Avoid contact with people who are coughing or sneezing.
If in close contact with infected persons keep at least one metre
away.
Immunisation for seasonal influenza if in second or third
trimesters during winter.5
Summary
Most cases of pandemic H1N1 influenza have been a mild to
moderate disease, but pregnant women infected with pandemic
H1N1 influenza appear to have an increased risk of complications
when compared with non-pregnant women of similar age and
the general population. Prevention with PanVax H1N1 pandemic
influenza vaccine (CSL) is recommended for pregnant women. The
benefits of treatment with appropriate antivirals appear to outweigh
the risks, especially in the second and third trimester, and are more
effective when commenced within 48 hours of illness. Doctors
should not delay treatment while awaiting test results. Women who
become infected should be treated symptomatically, including the
use of antipyretics. Doctors should continue to be guided by local
health authorities as further information continues to come to light.
References
1.
World Health Organisation. World now at start of 2009 influenza

pandemic: www.who.int/mediacentre/news/statements/2009/h1n1_
pandemic_phase6_20090611/en/index.html .
2. Thorner AR, Hirsch MS, McGovern BH. Epidemiology, clinical
manifestations, and diagnosis of pandemic H1N1 influenza (swine
influenza). Up To Date. August 2009.
3. www.emergency.health.nsw.gov.au/swineflu/pregnancy/index.asp
4. United States Centre for Disease Control and Prevention. Interim
guidance on antiviral recommendations for patients with novel
influenza A (H1N1) virus infection and their close contacts:
www.cdc.gov/h1n1flu/recommendations.htm .
5. New South Wales Department of Health: www.health.nsw.gov.au/ .
6. Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza
virus infection during pregnancy in the USA. The Lancet 2009;
374:451-458.
7. Weinberger SE, Lockwood CJ, Barss VA. Dyspnea during pregnancy.
Up to Date. May 2009.
List of references continued on page 45.
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ANZJOG
Volume
49
Number
2 April 2009
Clinical
& Experimental
Ophthalmology
THREE
LINES OF
VISION
TO HIM,
ITS THE WORLD
The vision loss caused by neovascular
AMD is devastating and extremely
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vision. By allowing them to maintain
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Information
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Brown714,
MM, et 875
al. Can Pacific
J Ophthalmol.
2005;40:277-287.
2. Williams
RA, et al.
Arch Ophthalmol.
1998;116:514-520.
3. Novack
GD. Ann Revof
Pharmacol
Toxicol. 29008:48:61-78.
4. Dalton M.AU.WH.06.2008.0020
Treatment regimens for AMD focussing on antiRegistered
trademark
the Bayer
group, Germany.
NSW
2073. YAZ
VEGF. EyeWorld January 2007. Available at: http://www.nei.nih.gog/health/maculardegen/armd_facts.asp. Accessed 10 Jan 2008. 5. Rosenfeld PJ, et al. N Engl J Med.
2006;355:1419-1431. 6. Brown DM, et al. N Engl J Med. 2006;355:1432-1444. 7. LUCENTIS Approved Product Information. 8. Data on le. 9. Chang TS, et al. Arch
Ophthalmol. 2007;125:1460-1469. Novartis Pharmaceuticals Australia Pty Limited, ABN 18 004 244 160. 54 Waterloo Road,
5,6,9
North Ryde NSW 2113. Novartis Pharmaceuticals Australia Pty Limited. NVO_LUC66_11/2008. Bluedesk LUC3C.
Pages 119Volume
240 37, Number 4, May/June 2009 Pages 333426
GAINED *
Clinical & Experimental

Ophthalmology
The Australian and
New Zealand Journal
of Obstetrics and
Gynaecology
Volume 37, Number 4, May/June 2009
ISSN 1442-6404
ANZJOG
Confocal microscopy of the bulbar conjunctiva
Bleb imaging with spectral domain OCT
Chemotherapy for sebaceous gland carcinoma

Nasolacrimal canal diameter by CT scan
Volume 49
Number 2
April 2009
Risk factors in ocular trauma
Polypoidal choroidal vasculopathy in AMD

PCV in peripapillary AMD
Imaging of macular hole formation
124 Robotics in gynaecology

130 Periodontal disease
198 Laparoscopic hysterectomy
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Gynaecological Management Update: Womens Health
The myth of screening for

epithelial ovarian cancer
Can we finally lay it to rest?
Ovarian cancer screening has been the Holy Grail for both researchers and
clinicians who manage patients with ovarian cancer. Because most patients
diagnosed with epithelial ovarian cancer are diagnosed at a late stage, the
disease has a high mortality rate.
Dr Alison Brand
FRANZCOG
This has led to the desire for a screening

test that will detect the disease at
an early stage so that the five-year
survival would be markedly improved.
Unfortunately, it has become increasingly
clear over the past few years that there is
no effective population-based screening
test for epithelial ovarian cancer (EOC).
There are several reasons for this and I
will review them in this article.
Epithelial ovarian cancers are the eighth most common invasive

malignancy in Australian women, but the leading cause of death
from gynaecological cancer. In 2005, approximately 1200
women were diagnosed with the disease and almost 900 died
from it.1 Epithelial ovarian cancer has been called the whispering
disease because the symptoms are vague and common, and
often attributed by both patient and their doctors to menopause
or benign conditions such as irritable bowel syndrome. In
addition, the symptoms are more often gastrointestinal than
strictly gynaecological, thus confusing the picture and leading to
inappropriate investigations and commonly delayed referral.
Although research continues, at

present, there is no effective
screening tool for the early
diagnosis of ovarian cancer in the
average or high-risk woman
and such screening is not
recommended.
As a result of diagnostic difficulties due to lack of specific signs
and symptoms, 70 per cent of patients will present with advanced
disease with metastases to peritoneal surfaces, omentum, or lymph
nodes (stage 3), or liver parenchyma or lungs (stage 4). Five-year
survival at this stage is a meagre 25 to 30 per cent compared to
those who present with stage 1 disease (confined to the ovary)
whose five-year survival will be about 90 per cent.
It is this discrepancy between survival at stage 1 as compared to
advanced stages that has led to such an interest in screening tests
for ovarian cancer, in the hope the disease could be detected early,
with resulting improved survival.
The World Health Organisation (WHO) has defined the

requirements for effective population-based screening tests (see
Table 1). The lack of efficacy of ovarian cancer screening can be
attributed to both the disease and the screening tests available.
Table 1.
WHO criteria for screening
Disease
Significant health problem, with latent or early

symptomatic stage. The natural history should be well
understood.
Screening test
Simple, safe, relatively non-invasive, sensitive and

specific.
Treatment
Effective, with evidence that early treatment improves

outcome.
Screening
program
Acceptable to screened population and cost-effective.
Adapted from Wilson JM, Jungner G. Principles and practice of screening

for disease. Public Health Paper Number 34. Geneva: WHO, 1968.
Screening
The disease
In the past, it was thought that there was a steady progression
from early stage to late stage disease, thus allowing the chance
to intervene with surgery for early disease. It is now postulated,
especially for high-grade serous tumours (the most common
histological subtype which accounts for 70 per cent of all
epithelial ovarian cancers), that they often arise de novo with no
recognisable precursor lesion. They are also often multifocal and
appear to progress rapidly, leaving little time for early detection or
intervention.2 If this is the true model of their biologic behaviour,
then it is not surprising that screening for ovarian cancer has not
been successful.
The screening tests
The CA-125 blood test and transvaginal ultrasound, either alone
or in combination, have been studied as screening tests. The work
of Jacobs in the United Kingdom and van Nagell in the United
States, in several large prospective studies in the 1980s and 1990s,
showed that screening was feasible.3,4 What these studies were not
able to determine was whether the overall survival of the screened
group was any better than that of an unscreened population.
Two large randomised controlled trials which attempt to answer that
question have recently reported preliminary results. The US National
Womens Health : Gynaecological Management Update

Cancer Institute has sponsored a large, multicentre prospective
randomised screening trial of 34,261 postmenopausal women as
part of the Prostate, Lung, Colorectal and Ovarian Cancer (PLCO)
Project.5 The women were randomised to both yearly transvaginal
ultrasound (TVUS) and CA-125 for four years followed by CA-125
only, for two more years, or usual gynaecological care (control
group). In the screening arm, 60 invasive cancers were discovered,
but only 28.3 per cent were early stage. In addition, 19 interval
cancers (those cancers discovered within a year of a negative
screen) were found and only 16 per cent of those were early stage.
Thus, only one quarter of the patients were diagnosed with early
stage cancer and one quarter were missed by both screening tests.
The specificity of the tests was so poor that almost 20 surgical
procedures were required to diagnose one cancer and 75 per cent
of these cancers were late stage (3 or 4). It is therefore apparent
that, in this study, TVUS and CA-125 screening did not meet the
WHO requirement for test specificity.
The preliminary results for the screened arm of a large randomised
trial conducted in the UK were also reported earlier this year. Over
200,000 postmenopausal women were randomly assigned to three
groups as part of the UK Collaborative Trial of Ovarian Cancer
Screening (UKTOCS): a control arm that received no screening; an
arm that underwent annual CA-125 testing with TVUS as a second
line test; and an arm that underwent annual screening ultrasound.6
There were approximately 45 cancers detected in each of the
two screening arms, of which only 59 were invasive cancers and
less than half (28) were of an early stage. There were 13 interval
cancers. Significantly, the results in the unscreened population were
not reported. The endpoint of interest overall mortality rates will
be reported in 2014.
A large prospective Japanese population-based study of 82,487
postmenopausal women reported that there was no statistically
significant increase in the number of early stage cancers identified
in a screened (pelvic ultrasound and CA-125) group compared to
an unscreened population (18 vs 14).7 Mortality data should be
available soon.
As a result of this information and other data, The Royal Australian
and New Zealand College of Obstetricians and Gynaecologists,
(and others, including The Royal Australian College of General
Practitioners, the Australian Society of Gynaecologic Oncologists,
Cancer Council Australia and the Screening Subcommittee of the
Department of Health and Ageing) recently endorsed the National
Breast and Ovarian Cancer Centres new position statement
regarding routine population-based screening of asymptomatic
women for ovarian cancer. The advice now unequivocally states
that: there is currently no evidence that any test, including pelvic
examination, CA-125 or other biomarkers, ultrasound (including
transvaginal ultrasound), or combination of tests, results in
reduced mortality from ovarian cancer and, furthermore, there
is no evidence to support the use of any test, including pelvic
examination, CA-125, or other biomarkers, ultrasound (including
transvaginal ultrasound), or combination of tests, for routine
population-based screening for ovarian cancer.8
So where to now?
General population
There are many investigators around the world attempting to
develop a more sensitive and specific screening test for ovarian
cancer by using a combination of markers. Only time will tell
whether or not a panel of markers will be sensitive, specific and
cost-effective enough to be used in the general population.
Regardless, many women naturally fear the diagnosis of ovarian
cancer and want earlier diagnosis and treatment. The National
44 O&G Magazine
Breast and Ovarian Cancer Centre has developed a number of

strategies to raise awareness of ovarian cancer symptoms in the
general population, as well as a guide for family doctors (available
on their website at www.nbocc.org.au), to help aid prompt
diagnosis and appropriate referral. In addition, the use of the risk
of malignancy index (see Table 2) is very helpful in triaging patients
who may need referral to a specialist gynaecologic oncology
unit. The risk of malignancy index was developed by Jacobs and
colleagues and uses menopausal status, ultrasound features and
absolute level of CA-125 to determine the likelihood of malignancy
being present in a patient with a pelvic mass.9
Table 2.
Criteria
Menopausal status
Premenopausal
Postmenopausal
Ultrasonic features
Multiloculated
Solid areas
Bilaterality
Ascites
Metastases
Serum CA-125
Scoring system
1
3
Score
A (1 or 3)
no feature = 0
one feature = 1
> one feature = 3
B (0, 1 or 3)
Absolute level (U/ml)
Risk of malignancy
index (RMI)
C
AXBXC
A cut-off value of 200 is used to discriminate benign from malignant

ovarian masses, with a sensitivity of 87%, specificity of 97% and positive
predictive value of >90%.
Jacobs I, et al. Br J Obstet Gynaecol. 1990.
High-risk groups
Approximately ten per cent of epithelial ovarian cancers are thought
to arise due to the inheritance of mutations in breast or ovarian
cancer-related genes, BRCA1 and BRCA2. Women who have
been found to carry a mutation in either BRCA1 or BRCA2 are at
markedly increased risk of developing ovarian cancer (up to 40 to
60 per cent lifetime risk for BRCA1 and up to 20 per cent risk for
BRCA2).
A number of studies have confirmed that annual screening for
ovarian cancer in BRCA1 and BRCA2 gene mutation carriers, or
in patients with strong family history, using transvaginal ultrasound,
CA-125 or other markers, is ineffective in detecting tumours at an
early enough stage to impact on survival.10,11 This is not particularly
surprising as serous cancers (noted above to be rapidly progressive)
are the predominant subtype of ovarian cancer in women with
BRCA1 or BRCA2 mutations. Based on such evidence, routine
screening is not recommended for high-risk women or BRCA
mutation carriers.12
The only intervention that has been shown to be effective in
reducing the incidence of ovarian cancer in women carrying
the BRCA1 and BRAC2 gene mutations is bilateral salpingooophorectomy (BSO).13 Risk-reducing salpingo-oophorectomy
(RRSO) is an important preventive measure in BRCA mutation
carriers and, in our breast/ovarian risk management clinic at
Westmead Hospital, Sydney, the uptake of BSO is 80 per cent.
Although this surgery has not been evaluated in randomised trials,
retrospective and prospective cohort studies indicate that RRSO will
reduce the risk of BRCA-associated ovarian and tubal cancers by
80 to 96 per cent and, if performed in premenopausal women, will
reduce the risk of breast cancer by approximately 50 per cent.14
This latter effect is most likely due to the induction of premature
Gynaecological Management Update: Womens Health

menopause, although breast cancer risk reduction does not seem
to be affected by short-term hormone replacement therapy after
BSO.15
It is important to note that tubes and ovaries should be removed
in their entirety, as all the epithelial surface is at risk. There are
divided opinions as to whether the uterus should be removed at the
same time, with some theoretical concerns that the uterus may be
at risk, either due to the intramural portion of the tube or because
of the risk of endometrial cancer. In addition, tamoxifen and HRT
administration is less complicated in the absence of a uterus. A
discussion about the timing and extent of the surgery is too complex
for this article and patients at high risk or potentially high risk
because of their family history may be best served by referral to
a familial cancer centre for assessment of their risk, discussion of
genetic testing and decisions regarding risk-reducing surgery.
Conclusion
Although research continues, at present, there is no effective
screening tool for the early diagnosis of ovarian cancer in the
average or high-risk woman and such screening is not
recommended.
5.
6.
7.
8.
9.
10.
11.
12.
References
1.
Australian Institute of Health and Welfare (AIHW) 2007. ACIM

(Australian Cancer Incidence and Mortality) Books. AIHW: Canberra.
Hogg R, Friedlander M. Biology of epithelial cancer: implications for
screening women at high genetic risk. JCO 2004; 22(7):1315-27.
Jacobs I, Davies AP, Bridges J, Stabile I, Fay T, Lower A,
Grudzinskas JG, Oram D. Prevalence screening for ovarian
cancer in postmenopausal women by CA 125 measurement and
ultrasonography. BMJ 1993; 306(6884):1030-4.
van Nagell JR Jr, DePriest PD, Reedy MB, Gallion HH, Ueland
FR, Pavlik EJ, Kryscio RJ. The efficacy of transvaginal sonographic
screening in asymptomatic women at risk for ovarian cancer. Gynecol
Oncol. 2000; 77:350-6.
2.
3.
4.
13.
14.
15.
Partridge E, Kreimer AR, Greenlee RT, Williams C, Xu J, Church TR, et

al for The Prostate, and Lung, Colorectal, and Ovarian Cancer (PLCO)
Project Team. Results from four rounds of ovarian cancer screening in
a randomized trial. Obstet Gynecol. 2009;113:775-782.
Menon U, Gentry-Maharaj A, Hallett R, Ryan A, Burnell M, Sharma A,
et al. Sensitivity and specificity of multimodal and ultrasound screening
for ovarian cancer, and stage distribution of detected cancers: results
of the prevalence screen of the UK Collaborative Trial of Ovarian
Cancer Screening (UKCTOCS). Lancet Oncol. 2009; 10: 327-40.
Kobayashi H, Yamada Y, Sado T, Sakata M, Yoshida S, Kawaguchi
R, et al. A randomized study of screening for ovarian cancer: a
multicenter study in Japan. Int J Gynecol Cancer 2008;18:414-20.
Nelson AE, Francis J, Zorbas H. Population screening and early
detection of ovarian cancer in asymptomatic women. ANZJOG 2009;
49:448-50.
Jacobs I, Oram D, Fairbanks J, Turner J, Frost C, Grudzinskas JG.
The risk of malignancy index incorporating CA 125, ultrasound and
menopausal status for the accurate pre-operative diagnosis of ovarian
cancer. BMJ 1990; 97:922-9.
Olivier RI, Lubsen-Brand MA, Verhoef S, van Beurden M. CA125
and transvaginal ultrasound monitoring in high-risk women cannot
prevent the diagnosis of advanced ovarian cancer. Gynecol Oncol.
2006;100:20-6.
van der Velde NM, Mourits MJ, Arts HJ, et al. Time to stop ovarian
cancer screening in BRAC1/1 mutations carriers. Int J Cancer 2009;
124: 919-23.
National Breast and Ovarian Cancer Centre. Position Statement:
Surveillance of women at potentially high risk of ovarian cancer.
2009 [cited December 2009]. Available from: www.nbocc.org.au/ourorganisation/position-statements/ .
Kauff N, Domchek S, Friebel T, Robson ME, Lee J, Garber J. Riskreducing Salpingo-oophorectomy for the prevention of BRCA1- and
BRCA2-associated breast and gynecologic cancer: A multicenter,
prospective study. J Clin Oncol. 2008; 26:1331-37.
Robson M and Offit K. Management of an inherited predisposition to
breast cancer. N Engl J Med. 2007; 357:154-62.
Rebbeck TR, Friebel T, Wagner T, et al. Effect of short-term hormone
replacement therapy on breast cancer risk reduction after bilateral
prophylactic oophorectomy in BRCA1 and BRCA2 mutation carriers:
The PROSE Study Group. J Clin Oncol. 2005. 23:7804-10.
Swine flu in obstetrics. List of references continued from page 41.

8.
9.
10.
11.
12.
13.
14.
Ministry of Health. Reports on confidential enquiries into maternal

deaths in England and Wales: 1955-57. Reports on Public Health
and Medical Subjects (103). London: HMSO, 1960.
The ANZIC Influenza Investigators. Critical Care Services and 2009
H1N1 Influenza in Australia and New Zealand. NEJM 2009; 361:
1-10.
CDC. Prevention and control of influenza: recommendations of
the Advisory Committee on Immunization Practices (ACIP), 2008.
MMWR 2008; 57(No. RR-7).
Abdel-Ghafar AN, Chotpitayasunondh T, Gao Z, et al. Update on
avian influenza A (H5N1) virus infection in humans. N Engl J Med.
2008; 358:261-73.
Acs N, Banhidy F, Puho E, Czeizel AE. Maternal influenza during
pregnancy and risk of congenital abnormalities in offspring. Clin
Mol Teratol. 2005; 73:989-996.
Rasmussen SA, Jamieson DJ, Bresse JS. Pandemic influenza and
pregnant women. EmergInfect Dis. 2006; 14:95-100.
www.healthemergency.gov.au/internet/healthemergency/publishing.
nsf/Content/news-180909 .
Asia Pacific Committee

Involved in a developing country?
Wed love to hear from you!
The APC is keen to be kept informed about
activities and involvement of our Fellows in all
developing countries, but particularly the Asia
Pacific region. From this information we will be
able to increase valuable networks and build
a more comprehensive picture of the involvement
of College Fellows in the region, either under the
auspices of the College or via other avenues
or personal connections you may have.
Please send one paragraph outlining details of
any activities/projects/consultations you have been
involved in over the past year or details of activities
you will be involved in for the coming year to:
Carmel Walker
Coordinator Asia Pacific Services
(e) cwalker@ranzcog.edu.au
Womens Health
Journal Club
Had time to read the latest journals? Catch up on some recent O and G research by
reading these m
ini-reviews by Dr Brett Daniels.
Rapid decline in
presentations for
genital warts
The quadrivalent HPV vaccine chosen
by the Australian Government for their
free human papillomavirus (HPV) vaccine
program protects against types 6 and 11, associated with
genital warts, as well as types 16 and 18, associated with
cervical cancer. This Australian paper reports on changes in
the number of presentations for genital warts at the Melbourne
Sexual Health Centre. From January 2004 to December
2008, over 36,000 new clients, men and women of all ages,
presented to the centre, with 3826 cases of genital warts
diagnosed. The Australian Government rolled out a free HPV
vaccination program for women up to 26 years of age in July
2007. The authors analysed changes in the rate of diagnosis
of genital warts in a number of age and sex groups. Their
results show a 25 per cent decline in the number of women
under 28 years of age presenting with genital warts after the
end of 2007. Prior to this there had been a small quarterly rise
in presentations. The authors also found a significant decline
in genital warts in heterosexual men after 2007. There was
no decline seen in women over 28 years of age or in men
exclusively having sex with men. This study provides compelling
evidence of the effectiveness of the quadrivalent HPV vaccine
in reducing genital wart infection in women. It also raises
questions regarding the wider public health implications of HPV
vaccination in young women.
Fairley CK, Hocking JS, Gurrin LC, Chen MY, Donovan B, Bradshaw
C. Rapid decline in presentations for genital warts after the
implementation of a national quadrivalent human papillomavirus
vaccination program for young women. Sexually Transmitted Infections
2009. Published online 16 Oct 2009.
Mifepristone for treatment of

uterine leiomyoma
Uterine fibroids are a common gynaecological problem often
leading to increased bleeding, discomfort and reduced quality
of life. While surgical treatment is often utilised for treatment
of fibroids, this study investigates the use of medical treatment
with the anti-progesterone mifepristone. The authors recruited
30 women who had been scheduled for surgical treatment for
fibroids and randomly allocated them to receive either placebo
or 50mg mifepristone every second day for three months.
Endometrial biopsies were performed at the beginning and end
of the study, while uterine size and blood flow were evaluated
sonographically each month. The results showed that three
months treatment with mifepristone 50mg resulted in a
significant reduction in fibroid size, reduced bleeding and
increased blood haemoglobin. While this is an encouraging
result, the major limitation of this study is the small sample size
and short duration of treatment. Unfortunately, the authors did
46 O&G Magazine
Selective serotonin reuptake

inhibitors in pregnancy
Most doctors caring for pregnant women would have been
faced with patients suffering from depression. It is estimated
that up to 20 per cent of pregnant women may suffer from
depression and pharmacotherapy remains an important
component of treatment in many cases. Recommendations that
pregnant women should commence antidepressants causes
anxiety for both the woman and her doctor, with inevitable
concerns about the fetal effects of these medications. The
most commonly used antidepressants in current practice are
selective serotonin reuptake inhibitors (SSRIs) and it is the fetal
effects of SSRIs that is the subject of this Danish study. The
authors analysed data from 496,000 singleton live births in
Denmark between 1996 and 2003, linking databases of filled
prescriptions, demographic information about pregnancies,
and diagnoses of congenital malformations. Of these
pregnancies, 1370 were exposed to one or more SSRIs at
between four and 16 weeks gestation. The majority of
prescriptions were for sertraline, fluoxetine, citalopram or
paroxetine. The results showed that septal heart defects were
more common in women who had received SSRIs in the first
trimester of pregnancy. In particular, sertraline (OR=3.25,
1.21-8.75) and citalopram (OR=2.52, 1.04-6.10) were
associated with septal heart defects but not fluoxetine or
paroxetine. A larger risk was found if more than one SSRI was
used (OR=4.70, 1.74-12.7). The absolute risk of septal heart
defects was 0.5 per cent in unexposed women, one per cent in
those exposed to one SSRI and two per cent for those exposed
to more than one SSRI. There was no association with SSRI use
and non-cardiac malformations. This paper, in
conjunction with previous studies, will further help clinicians
counsel patients on the use of antidepressants in pregnancy,
especially during the first trimester.
Pedersen LH, Henriksen TB, Vestergaard M, Olsen J, Bech BH.
Selective serotonin reuptake inhibitors in pregnancy and congenital
malformations: population-based cohort study.
BMJ 2009; 339, b3569.
not report the duration of relief once the course of

mifepristone was ceased. Similarly, they acknowledged that
they were unable to comment on the safety of mifepristone
used for an extended period. Indeed, they reported that of the
eight women receiving mifepristone in which they were able
to evaluate the endometrium, seven had a non-physiological
appearance. These issues will need to be addressed in future
studies.
Engman, M, Granberg, S, Williams, ARW, Meng, CX, Lalitkumar,
PGL, K. Gemzell-Danielsson, K. Mifepristone for treatment of uterine
leiomyoma. A prospective randomized placebo controlled trial.
Human Reproduction 2009; 24, 18701879.
Meetings and Conferences
Meetings Calendar
LEGEND
Summer 2009

A
A/P
P
O
B
RANZCOG Approved Meetings evidence of attendance required

Practice Review & Clinical Risk Management (PR&CRM) activity
associated with meeting
Practice Review & Clinical Risk Management (PR&CRM) activity
Category to be determined
Other meetings category
Australia
2010 onwards
4February 2010
19-20 Feb 2010 O
The Anatomy of Complications

Workshop
Perth WA
Contact Ms Wendy Rutherford
(t) +61 8 9340 1393
(f) +61 8 9340 1063
(e) wendy.rutherford@health.
wa.gov.au
(w) www.acworkshop.com
21 Feb 2010 O
100 years of Australian Medical

Research
Sydney NSW
Contact
(w) www.cs.nsw.gov.au/rpa/
museum
4March 2010
1-5 Mar 2010 O
SWEC Advanced Gynaecologic

Laparoscopic Surgery Course
Sydney NSW
Contact Suite 1
2 Pearl Street Hurstville
NSW 2220
(t) +61 2 9579 3110
(m) +61 400 037 699
(f) +61 2 9580 2348
(e) swec@swec.com.au
(w) www.swec.com.au
3-4 Mar 2010 O
12th Annual Health Congress

Reforming health in the best
interests of the patient
Sydney NSW
Contact Informa Conferences
GPO Box 2728 Sydney
NSW 2001
(t) +61 2 9080 4307
(f) +61 2 9290 3844

(e) registration@informa.com.
au
(w) www.informa.com.au/
healthcongress
20-21 Mar 2010 O

ASUM Multidisciplinary
Workshop 2010
Brisbane QLD
Contact ASUM
(t) +61 2 9438 2078
(f) +61 2 9438 3686
(e) asum@asum.com.au
(w) www.asum.com.au
20-21 Mar 2010 O

Annual O&G Symposium
Brisbane QLD
Contact ASUM
(t) +61 2 9438 2078
(f) +61 2 9438 3686
(w) www.asum.com.au
21-24 Mar 2010 A
2010 RANZCOG ASM

Adelaide SA
Contact Waldron Smith
Management 61 Danks Street
West Port Melbourne
VIC 3207
(t) +61 3 9645 6311
(f) +61 3 9645 6322
(e) ranzcog2010asm@wsm.
com.au
(w) www.ranzcog2010asm.
com.au
Conference 20 points, Opening
Ceremony 2 points, Breakfast
sessions 1 point per session
4May 2010
1-2 May 2010 O
ASCCP 2-day Colposcopy

Course 2010
Melbourne VIC
Contact
(w) www.asccp.com.au/
14-15 May 2010 O

Workshop
Perth WA
(t) +61 8 9340 1393
(f) +61 8 9340 1063
wa.gov.au
27-29 May 2010 O
19th ISGE Congress in

conjunction with AGES XX
Annual Scientific Meeting
Sydney NSW
Contact Conference
Connection 282 Edinburgh
Road Castlecrag NSW 2068
(t) +61 2 9967 2928
(f) +61 2 9967 2627
(e) conferences@ages.com.au
4June 2010
16-18 Jun 2010 O
Inaugural National Indigenous

Drug & Alcohol Conference
(NIDAC 2010)
Adelaide SA
Contact NIDAC 2010
Organiser c/o Eventcorp Pty Ltd
PO Box 3873 South Brisbane
BC QLD 4101
(t) +61 7 3334 4460
(f) +61 7 3334 4499
(w) www.nidaconference.com.
au
4July 2010
1-4 Jul 2010 O
Breathing New Life into

Maternity Care
Alice Springs NT
Contact Ms Therese Kramer
Remark PO Box 10
Petersham NSW 2049
(t) +61 2 9517 3664
(f) +61 2 9517 2662

(e) therese@remark.com.au
(w) www.breathingnewlife.
remark.com.au
9-10 Jul 2010 O

Workshop
Perth WA
(t) +61 8 9340 1393
(f) +61 8 9340 1063
wa.gov.au
19-23 Jul 2010 O

Sydney NSW
Contact Suite 1
NSW 2220
(t) +61 2 9579 3110
(m) +61 400 037 699
(f) +61 2 9580 2348
(w) www.swec.com.au
4September 2010
Sep 2010 O
ASUM Annual Scientific Meeting

Contact ASUM
(t) +61 2 9438 2078
(f) +61 2 9438 3686
(w) www.asum.com.au
26-29 Sep 2010 O
14th Australasian Menopause

Society Congress in conjunction
with the 4th Scientific Meeting
of the Asia Pacific Menopause
Federation
Sydney NSW
Contact APMF Meeting
Managers
(t) +61 2 9265 0700
(f) +61 2 9267 5443
(e) apmf2010@arinex.com.au
(w) www.apmf2010.com
4October 2010
7-10 Oct 2010 O
GP10
Cairns QLD
Contact (w) www.gp10.com.au
11-15 Oct 2010 O

Sydney NSW
Contact Suite 1
NSW 2220
(t) +61 2 9579 3110
(m) +61 400 037 699

(f) +61 2 9580 2348
(w) www.swec.com.au
15-16 Oct 2010 O
Overseas
2010 onwards

Workshop
Perth WA
(t) +61 8 9340 1393
(f) +61 8 9340 1063
wa.gov.au
4January 2010
2011
19-22 Jan 2010 O
12-15 Oct 2011 O
2011 RANZCOG ASM

Melbourne VIC
Contact Ms Kylie Grose
RANZCOG
254-260 Albert Street
East Melbourne VIC 3002
(t) +61 3 9412 2922
(f) +61 3 9419 0672
(e) kgrose@ranzcog.edu.au
(w) www.ranzcog.edu.au
New
Zealand
2010 onwards
28-31 Mar 2010 O
PSANZ 2010 14th Annual

Congress of the Perinatal
Society of Australia and New
Zealand
Wellington New Zealand
Contact PSANZ 2010 Congress
Managers
c/- Event Planners Australia
PO Box 1517 Eagle Farm
QLD 4009 Australia
(t) +61 7 3858 5580
(f) +61 7 3858 5499
(e) psanz2010@eventplanners.
com.au
(w) http://pwanz2010.
eventplanners.com.au
24-27 Nov 2010 O
New Zealand Committee

Dunedin New Zealand
Contact Ms Kate Bell
Level 3 Navigate House
69 Boulcott Street Wellington
New Zealand
(t) +64 4 472 4608
(f) +64 4 472 4609
(e) k.bell@ranzcog.org.nz
48 O&G Magazine
6-7 Jan 2010 A
BFS Annual Meeting 2010

Bristol UK
Contact
(w) www.fertility.or.uk/meetings/
forthcoming
16 points
53rd AICOG
Guwahati India
Contact
(w) www.aicog2010.org
20-23 Jan 2010 O
1st International Congress on

Womens Health & Unsafe
Abortion
Bangkok Thailand
Contact
(e) womenhealthcongress@
gmail.com
(w) www.womenhealth.or.th
4February 2010
1-4 Feb 2010 O
2nd International Conference

on Drug Discovery & Therapy
Dubai UAE
Contact (w) www.icddt-bio.com
1-6 Feb 2010 O
Society for Maternal Fetal

Medicine 30th Annual Meeting
The Pregnancy Meeting
Chicago USA
Contact (w) www.smfm.org
10-13 Feb 2010 O
36th Annual Meeting off the

North American Society for
Psychosocial Obstetrics and
Gynaecology
Richmond USA
Contact (w) www.naspog.org
17-20 Feb 2010 O
Cervical Cancer Prevention: 20

Years of Progress and a Path to
the Future
Monte Carlo Monaco
Contact
(w) www.eurogin.com/2010
18-21 Feb 2010 O
International Society for the

Study of Womens Sexual Health
St Petersburg USA
Contact (w) www.isswsh.org
25-28 Feb 2010 O
First International Congress on

Cardiac Problems in Pregnancy
Valencia Spain
Contact Shlomit Benartzy
Conference Coordinator
CPP Meeting Paragon
Conventions
Part of Liberty International
(t) +41 22 533 0948
(f) +41 22 580 2953
(e) secretariat@cpp2010.com
(w) www.cpp2010.com
1st Latin America Controversies

to Consensus in Diabetes,
Obesity and Hypertension
(CODHy)
Buenos Aires Argentina
Contact
(w) www.codhy.com/argentina/
19-21 Mar 2010 O
2010 APAGE International

Workshop on Animal Hands
on Lab
Shanghai China
Contact
(e) mit.apage@gmail.com
(w) www.apagemit.com
24-27 Mar 2010 O
SRS & CRS 19th Annual

Scientific Meeting
Singapore
Contact
(w) http:/singaporeradiology
2010.com
7th Annual Advances in

Surgical Gynecology & Female
Sexuality
Arizona USA
Contact
(e) sedonainfo@gmail.com
4March 2010
25-28 Mar 2010 O
4-6 Mar 2010 A
Berlin International Symposium/

Perinatal Programming The State of the Art
Berlin Germany
Contact
(w) www.perinatalprogramming-2010.de
22 points
4-7 Mar 2010 O
Asian American Multi Specialty

Summit IV Laparoscopy &
Minimally Invasive Surgery
Hawaii USA
Contact (w) www.SLS.org
14-16 Feb 2010 O
6-10 Mar 2010 O
Obs-Gyne Middle East Meeting

2010
Dubai UAE
Contact (w) www.obs-gyne.com
11-14 Mar 2010 O
25-28 Feb 2010 O
14th World Congress of

Gynaecological Endocrinology
(ISGE)
Firenze Italy
Contact Biomedical
Technologies
srl Via Trieste 1
56126 Pisa ITALY
(f) +39 0 50 501239
(e) isge2010registrations@
biomedicaltechnologies.com
(w) www.gynecological
endocrinology.org
10-13 Feb 2010 O
Contact Dr Ali Sungkar

Himpunan Kedokteran
Fetomaternal Jakarta Jl Kimia
No 5 Jakarta 10320 Indonesia
(t) +62 21 3928 721
(f) +62 21 3915 041
(e) secretariat@6wcpm2010.
com
(w) www.6wcpm2010.com
6th World Congress Perinatal

Medicine in Developing
Countries
Jakarta Indonesia
ISUOG 6th International

Scientific Meeting
Cairo Egypt
Contact
(e) info@isuogcairo2010.com
(w) www.isuogcairo2010.com
4April 2010
9-11 Apr 2010 O
3rd Congress of the Asia Pacific

Initiative on Reproduction
(ASPIRE 2010)
Bangkok Thailand
Contact Kenes Asia
2/F PICO Creative Centre
20 Kallang Avenue
Singapore 339411
(t) +65 6292 4706
(f) +65 6292 4721
(e) aspire2010@kenes.com
(w) www.kenes.com/aspire
9-11 Apr 2010 O
15th National Congress

on Assisted Reproductive
Technology and Advances in
Infertility Management
Kochi India
Contact (w) www.isar2010.org

22-25 Apr 2010 O
1st International Congress

on Controversies in
Cryopreservation of Stem Cells,
Reproductive Cells, Tissues and
Organs (CRYO)
Valencia Spain
Contact
(w) www.comtecmed.com/
cryo/2010
23-25 Apr 2010 O
62nd Annual Congress of the

Japan Society of Obstetrics &
Gynaecology
Tokyo Japan
Contact
MA Convention Consulting Inc
Dal 2 Izumi-shlji Bldg
4-2-6 Kojimachi Chiyoda-ku
Toyko 102-0083 Japan
(t) +81 3 5275 1191
(f) +81 3 5275 1192
(e) jsog62@macc.jp
4May 2010
5-8 May 2010 O
21st European Congress of

Obstetrics & Gynaecology
(EBCOG 2010)
Antwerp Belgium
Contact Semico nv Korte Meer
16 9000 Gent Belgium
(t) +32 9 233 8660
(f) +32 9 233 8597
(e) EBCOG@semico.be
(w) www.EBCOG2010.be
15-19 May 2010 O
58th Annual Clinical

Meeting of the American
College of Obstetricians and
Gynecologists (ACOG 2010)
Contact (w) www.acog.org/acm
19-20 May 2010 O
15th Annual International

Conference of Obstetrics &
Gynaecology
Cairo Egypt
Contact (w) www.asogic.com
19-22 May 2010 O
11th Congress of the European

Society of Contraception
and Reproductive Health
Culture, Communication,
Contraception
The Hague, Netherlands
Contact European Society
of Contraception and
Reproductive Health
Mr. Peter Erard Opalfeneweg 3
1740 Ternat
(t) +32 2 582 08 52
(f) +32 2 582 55 15
(e) congress@contraception-
esc.com or esccentraloffice@
contraception-esc.com
(w) www.contraception-esc.com
19-23 May 2010 O
19th Wonca World Conference

of Family Doctors
Cancun Mexico
Contact
(w) www.wonca2010cancun.
com
26-29 May 2010 O
XXII European Congress of

Perinatal Medicine
Granada Spain
Contact MCA Events
sri Via G Pellizza da Volpedo
4 20149 Milano Italy
(t) +39 02 3493 4404
(f) +39 02 3493 4397
(e) info@mcaevents.org
(w) www.ecpm2010.org
27-29 May 2010 O
5th Eropean Congress of

the European Federation for
Colposcopy and Cervical
Cancer
Berlin Germany
Contact (w) www.efc2010.de
4June 2010
20-23 Jun 2010 A
32nd British International

Congress of Obstetrics and
Gynaecology
Belfast UK
Contact
Hampton Medical Conferences
Ltd 113-119 High Street
Hampton Hill Middlesex
TW12 1NJ UK
(t) +44 0 208 979 8300
(f) +44 0 208 979 6700
(e) info@bicog2010.com
(w) www.bicog2010.com
23 points
23-26 Jun 2010 O
World Congress Minimally

Invasive Gynaecologic Surgery
Contact
(w) www.hdge-hr.com/congress.
html
27-30 Jun 2010 A
26th Annual Meeting of the

European Society of Human
Reproduction & Embryology
(ESHRE)
Rome Italy
Contact
ESHRE Central Office
Meerstraat 60 B-1852
Grimbergen Belgium
(t) +32 0 2 269 09 69
(f) +32 0 2 269 56 00

(e) info@eshre.com
(w) www.eshre.com
23 points
4August 2010
23-27 Aug 2010 O
IUGA 2010 Joint meeting with

the International Continence
Society (ICS)
Toronto Canada
Contact (w) www.iuga.org
4September 2010
1-4 Sep 2010 O
19th SLS Annual Meeting &

Endo Expo 2010
New York USA
Contact Society of
Laparoendoscopic Surgeons
7330 SW 62 Place
Suite 410 Miami Florida
33143-4825 USA
(t) +305 665 9959
(f) +305 667 4123
(e) Abstracts@SLS.org
(w) www.SLS.org / www.
laparoscopy.org
11-16 Sep 2010 O
20th World Congress on Fertility

and Sterility
Munich Germany
Contact Professor D Healy
Level 5 Department of
Obstetrics and Gynaecology
246 Clayton Road
Clayton 3168
(t) +61 3 9594 5374
(f) +61 3 95946389
(e) karen.boland@med.
monash.edu.au
(w) www.iffs2010.com
22-26 Sep 2010 O
Global Congress of Maternal

and Infant Health
Barcelona Spain
Contact ONG Matres Mundi
c/ Londres, 6, p.8 08029
Barcelona Spain
(t/f) +34 934 190 015
(e) Barcelona2010@matresmundi.org
(w) www.globalcongress2010.
com
4October 2010
14-16 Oct 2010 O
11th Annual Congress of
APAGE
Singapore
Contact
(w) www.apagemit.com
23-26 Oct 2010 O
13th Biennial Meeting of the

International Gynecologic
Cancer Society (IGCS 2010)
Prague Czech Republic
Contact Kenes International
1-3 Rue de Chantepoulet
PO Box 1726 CH-1211
Geneva 1 Switzerland
(t) +41 22 908 0488
(f) +41 22 906 9140
(e) igcs13@kenes.com
(w) www2.kenes.com/igcs2010
28-30 Oct 2010 O
16th International Congress

of the International Society of
Psychosomatics Obstetrics and
Gynaecology (ISPOG)
Venezia Italy
Contact
(w) www.ispog2010.com
2011
8-12 Jun 2011 O
13th World Congress on the

Menopause
Rome Italy
Contact Mrs Jean Wright
International Menopause
Society PO Box 687
Wray Lancaster LA2 8WY UK
(t) +44 15242 21190
(f) +44 15242 22596
(e) jwright.ims@btopenworld.
com
(w) www.imsociety.org/world_
congress.html
4-7 Sep 2011 O
11th World Congress on

Endometriosis
Montpellier France
Contact AMS 11Bd. Henri IV
34000 Montpellier FRANCE
(t) +33 (0) 4 67 61 94 14
(f) +33 (0) 4 67 63 43 95
(e) mail@ams.fr
(w) www.wce2011.com
23-27 Sep 2011 O
XXII Asian & Oceanic Congress

of Obstetrics & Gynaecology
(AOCOG 2011)
Taipei Taiwan
Contact Ms Han Chiang
10F No 29 Sec 3
Nanjing E Road
Zhongshan District Taipei City
10487 Taiwan
(t) +886 2 2508 1825
(f) +886 2 2508 3570
(e) aocog2011@come2meet.
com
(w) www.aocog2011.org.tw

2012
2012 FIGO World Congress of
Gynecology and Obstetrics
Rome Italy
Contact (w) www.figo.org
RANZCOG
ASMs
2010-2013
2010
21-24 Mar 2010 A
2010 RANZCOG ASM

Adelaide SA
Contact Waldron Smith
Management 61 Danks Street
West Port Melbourne
VIC 3207
(t) +61 3 9645 6311
(f) +61 3 9645 6322
(e) ranzcog2010asm@wsm.
com.au
(w) www.ranzcog2010asm.
com.au
Conference 20 points, Opening
Ceremony 2 points, Breakfast
sessions 1 point per session
2011
12-15 Oct 2011 O
2011 RANZCOG ASM

Melbourne VIC
Contact Ms Kylie Grose
RANZCOG
254-260 Albert Street East
Melbourne VIC 3002
(t) +61 3 9412 2922
(f) +61 3 9419 0672
(e) kgrose@ranzcog.edu.au
(w) www.ranzcog.edu.au
2012
2012 RANZCOG ASM
Sydney NSW
24-27 Nov 2010 O

New Zealand Committee
Dunedin New Zealand
Contact Ms Kate Bell
Level 3 Navigate House
69 Boulcott Street
Wellington New Zealand
(t) +64 4 472 4608
(f) +64 4 472 4609
(e) k.bell@ranzcog.org.nz
RCOG
Meetings
and
Postgraduate
Courses
For further information on
RCOG Postgraduate Courses
Contact Conference Office
RCOG 27 Sussex Place
Regent's Park London
NW1 4RG
(t) +44 020 7772 6245
(f) +44 020 7772 6388
(e) conference@rcog.org.uk
(w) www.rcog.org.uk/meetings
MRANZCOG
Revision
Courses 2010
3-7 May 2010
MRANZCOG Pre-Examination
Course
Melbourne VIC
Contact Fran Watson
Executive Officer RANZCOG
Victorian Committee
8 La Trobe Street Melbourne
VIC 3000
(t) +61 3 9663 5606
(f) +61 3 9662 3908
(e) fmwatson@ranzcog.edu.au
2013
2013 RANZCOG ASM
Canberra ACT
Provincial
Fellows and
Regional
Committee
ASMs
50 O&G Magazine
DRANZCOG
Revision
Courses 2010
3-5 Feb 2010
DRANZCOG Revision Course

Melbourne VIC
Contact Fran Watson
Victorian Committee
VIC 3000
(t) +61 3 9663 5606

(f) +61 3 9662 3908
28-30 Jul 2010
DRANZCOG Revision Course

Melbourne VIC
Contact Fran Watson
Victorian Committee
VIC 3000
(t) +61 3 9663 5606
(f) +61 3 9662 3908
Womens
Health
Courses
and Activities
20 Mar 2010
RANZCOG 2010 Annual

Scientific Meeting
Diplomates Day One: Office
Obstetrics
Adelaide SA
Contact
(e) www.ranzcog2010asm.com.
au
Womens Health Points to be
advised
21 Mar 2010
RANZCOG 2010 Annual

Scientific Meeting
Diplomates Day Two: Office
Gynaecology
Adelaide SA
Contact
(e) www.ranzcog2010asm.com.
au
Womens Health Points to be
advised
6 May 2010
2010 RANZCOG Provincial

Fellows Annual Scientific
Meeting
Diplomates Day One
(Ultrasound Workshop)
Tamworth NSW
Contact Ms Kate Lawrey
(t) +61 3 9412 2971
(f) +61 3 9415 9306
(e) klawrey@ranzcog.edu.au
Womens Health points to be
advised
7 May 2010
2010 RANZCOG Provincial

Fellows Annual Scientific
Meeting
Diplomates Day Two (Obstetrics

Day)
Tamworth NSW
Contact Ms Kate Lawrey
(t) +61 3 9412 2971
(f) +61 3 9415 9306
(e) klawrey@ranzcog.edu.au
Womens Health points to be
advised
7-10 Oct 2010
GP10
Cairns QLD
Contact (w) www.gp10.com.au
Various Dates
Advanced Life Support in
Obstetrics (ALSO)
Contact Ms Irene Vasilas
(t) +61 2 9531 5655
(f) +61 2 8209 4949
(e) irenev@hemcorp.com.au
ACRRM: 30 points
RACGP Category 1: 40 points
Various Dates
Effective & Safe AnteNatal
Shared Care
Contact Ms Robyn Foster
Townsville General Practice
Network
(t) +61 7 4725 8915
(e) rfoster@tgpn.com.au
Category 1: 40 points
Various Dates
Cervical Screening: Pap
technique (link to Chlamydia
testing), terminology, guidelines
and HPV
Contact Ms Philippa Davis
Cancer Council of Victoria
(t) +61 3 9635 5049
(e) philippa.davis@cancervic.
org.au
Various Dates
Cervical Screening Skills
Workshops
Contact Ms Diana Earl
Family Planning QLD
(t) +61 7 3250 0240
(e) dearl@fpq.com.au
Various Dates
The evolving world of cervical
screening
Contact Ms Philippa Davis
Cancer Council of Victoria
(t) +61 3 9635 5049
(e) philippa.davis@cancervic.
org.au
Various Dates
IUD Insertion Training
Contact Ellie Freedman Family
Planning NSW

(t) +61 2 8752 4340
(e) ellief@fpnsw.org.au
Various Dates
Sexual Health & Family
Planning Australia Certificate in
Reproductive & Sexual Health
Contact Dr Christine Read
Family Planning NSW
(t) +61 2 8752 4341
(f) +61 2 9716 5046
(e) christinr@fpnsw.org.au
Various Dates
Successfully Working with
Women and their Health:
A Program for International
Medical Graduates and Rural
GPs
Contact Hans Spanjer
Jean Hailes Foundation for
Womens Health
(t) +61 3 9349 7800
(f) +61 3 9820 0401
(e) Hans.Spanjer@rwav.com.au
Various Dates
Obstetrics & Gynaecology
Ultrasound FastTrack Workshop
Contact Mr Tony Davies
Australian Institute of
Ultrasound
(t) +61 7 5526 6655
(f) +61 7 5526 6041
(e) tony@aiu.edu.au
Clinical
Audits
Early Detection of Breast
Cancer by Mammographic
Screening
Contact Dr Frances Cumming
BreastScreen SA
(t) +61 8 8274 7156
(f) +61 8 8357 8146
(e) Frances.Cumming@health.
sa.gov.au
Active
Learning
Modules
SH&FPA Certificate in Sexual
and Reproductive Health
Module 1, 2 & 3
Queensland
Contact Maggie Baker Family
Planning Queensland
(t) +61 7 3250 0240
(e) education@fpq.com.au
Online
Media and
Distance
Education
Healthed Womens
HealthUpdate - Audiopack and
Distance CPD
NSW
Contact Healthed
PO Box 500 Burwood
NSW 1805
(t) +61 1300 797 794
(f) +61 1300 797 792
(e) info@healthed.com.au
(w) www.healthed.com.au
ACRRM: 8 core points
Colposcopy CD-ROM
Contact RANZCOG
PR&CRM Staff
(t) +61 3 9417 1699
(f) +61 3 9415 9306
(e) prcrm@ranzcog.edu.au
Female Cancers and
Psychosocial Care
Contact GPlearning Help Desk
(t) 1800 284 789
(f) 1800 257 053
(e) contactus@gplearning.
com.au
(w) www.gplearning.com.au
Menstrual Disorders Multiple
Choice Questions v2
Contact GPlearning Help Desk
(t) 1800 284 789
(f) 1800 257 053
(e) contactus@gplearning.
com.au
K2 Foetal Monitoring Training
System
Contact Mr Peter Hunt K2
Medical Systems Pty Ltd
(t) +61 3 9038 8352
(f) +61 3 9879 2627
(e) peter.hunt@k2ms.com
(w) http://training.k2ms.com
Pregnancy Advice and Support
Contact Kim Collins GPE
(t) +61 3 8699 0540
(e) kim.collins@racgp.org.au
Pregnancy Advice and Support Assessment
Contact Kim Collins GPE
(t) +61 3 8699 0540

(e) kim.collins@racgp.org.au (w)
www.gplearning.com.au
(t) +61 7 3251 5900

(e) primed.coordinator@
medeserv.com.au
Steroidal Contraception Family

Planning Australia
Contact Stacy Lemon
Genesis Ed
(t) +61 2 9870 8044
(f) +61 2 9878 8065
(e) admin@genesised.com.au
(w) www.thinkgp.com.au
Womens Health Active Learning

Module
Contact
Ms Samantha Elliott-Halls
HealthEd Pty Ltd
(t) +61 1300 797 794
(e) info@healthed.com.au
A Bio-Psychosocial look at
Menopause and Midlife webcast
The Jean Hailes Foundation for
Womens Health
Contact Kellie Armstrong
(t) +61 3 9562 6771
(e) education@jeanhailes.
org.au
Clinical
Attachments
Hormone Therapy webcast

Womens Health
(t) +61 3 9562 6771
org.au
MFM1006 Womens Health
Monash University
Contact Helen Vella
(t) +61 3 8575 2216
(e) helen.vella@med.monash.
edu.au
Polycystic Ovarian Syndrome
and Gestational Diabetes
What can we do?
Womens Health
(t) +61 3 9562 6771
(f) +61 3 9548 9120
org.au
Prescribing Hormone
Replacement Therapy: Weighing
up the evidence
Womens Health
Contact Stephanie Cook
(t) +61 3 9562 6771
(e) stephanie.cook@jeanhailes.
org.au
Short Course in Womens
Health: Updates in Antenatal
Care for GPs
Med-E-Serv Pty Ltd
Contact Pri-MeD Coordinator
Supervised Clinical Attachments

Womens Health
Contact Carolyn Wall
(t) +61 3 9562 6771
(e) carolyn.wall@jeanhailes.
org.au
Category 1 points and PDP
points are available
Womens Health activities follow
this link to visit the RACGP
website:
www.racgp.org.au
ACRRM Womens Health
activities follow this link:
www.acrrm.org.au/
To include your
meeting or
conference on
this list please
contact:
Val Spark
CPD Senior Coordinator
(t) +61 3 9412 2921
(f) +61 3 9419 7817
(e) vspark@ranzcog.
edu.au
To view the most
recent lists,
please go to:
www.ranzcog.edu.au/
meetingsconferences/
index.shtml
~ Call
for Abstracts.
Its not all

Black and White.
RANZCOG 2010
21-24 March 2010
Adelaide Convention Centre South Australia
SPONSORSHIP AND EXHIBITION PROSPECTUS
REGISTRATION
Early bird registration closes Friday 22 January 2010. Visit the meeting
website at www.ranzcog2010asm.com.au to download the Registration
Brochure and provisional program and to register online.
ANNUAL
SCIENTIFIC
MEETING
SOUTH AUSTRALIA
Fellow
$1,250.00
$1,450.00
Trainee / Diplomate
$ 935.00
$1,085.00
Pacific O&G Specialist
$ 625.00
$ 725.00
Retired Fellow / Midwife
$ 625.00
$ 725.00
$ 500.00
$ 650.00
Day Registration
Fellow
Trainee / Diplomate
$ 375.00
$ 485.00
Pacific O&G Specialist
$ 250.00
$ 325.00
Retired Fellow / Midwife
$ 250.00
$ 325.00
PRE-MEETING WORKSHOPS
The following interactive workshops are being held preceding the
RANZCOG 2010 ASM on Saturday 20 and Sunday 21 March 2010:

RANZCOG 2010 ASM
Early bird
Standard
MARCH
2010
on or before 21-24
on or
after
22 January 2010
23
January
2010
ADELAIDE CONVENTION
Full Registration
Keynote Speakers
Diplomates Day One: Office Obstetrics

Diplomates Day Two: Office Gynaecology
Training Supervisors Workshop
Anatomy Workshop
Robotic Surgery in Gynaecology Workshop
PROMPT RANZCOG Workshop
Giving O and G Evidence: A Mock Court and Report Writing Workshop
Minimally Invasive Surgery - AGES
PSANZ Perinatal Mortality Workshop
RANZCOG Fetal Surveillance Education Program
Participant numbers for each workshop is limited; early registration is

encouraged to avoid disappointment. Visit the meeting website for further
information regarding these exciting workshops.
Professor Zarko Alfirevic, United Kingdom

Mr Tim Draycott, United Kingdom
Dr Metin Glmezoglu, Switzerland
Professor Justus Hofmeyr, South Africa
Professor Horace Roman, France
Professor Jim Neilson, United Kingdom

CENTRE
Maximising Your Points

This meeting has been approved as a RANZCOG
accredited meeting and eligible Fellows, Associate
Members and Educational Affiliates of this College
will earn CPD points for attendance as follows:
> Full attendance (conference only)
> Attendance 22 March 2010
> Attendance Opening Ceremony
> Attendance Breakfast Sessions
> Points for pre-meeting workshops
to be advised once allocated
20 points
7 points
7 points
5 points
2 points
1 point
Points will be applied for with ACRRM and RACGP.

Both Diplomates Days and the Fetal Surveillance
Education Program Workshop are eligible for rural
procedural grants.
Further Information
RANZCOG ASM Secretariat
WALDRONSMITH MANAGEMENT
61 Danks Street West
Port Melbourne VIC 3207 Australia
T +61 3 9645 6311
F +61 3 9645 6322
E ranzcog2010asm@wsm.com.au
W ranzcog2010asm.com.au
www.ranzcog2010asm.com.au
REGISTER NOW - Early bird Registration Closes 22 January 2010
Womens Health
Q&a
Q&a attempts to provide balanced answers to those curly-yet-common questions in
obstetrics and gynaecology for the broader O&G Magazine readership including
Diplomates, Trainees, medical students and other health professionals.
An antenatal patient of mine has completed an independently-run birth

preparation course. Although most of her birth plan is reasonable, she has
been told not to agree to active management of the third stage and to refuse
an oxytocic. When I told her that was my standard practice, she challenged
me to convince her otherwise. How should I respond to this?
Prof Michael Permezel
Also, most women choose not to do anything that might increase

the risk of blood transfusion usually because of the (very small)
risk of contracting a blood borne virus from the transfusion.
FRANZCOG
Although it is an important principle that women

make an informed choice, it is also important that the
information that informs the choice is accurate and
presented in relatively simple terms.
I would suggest you say something along the following lines:

The large trials that have compared active management (that
is, giving an oxytocic, early cord clamping and controlled cord
traction) with physiological management have both shown a ten per
cent increase in the rate of postpartum haemorrhage and about a
two to three per cent increase in the need for blood transfusion.
Women who have a postpartum haemorrhage, although often not
needing a blood transfusion, have greater difficulty coping with the
early recovery from birth and the demands of their newborn baby.
The benefits of natural management are non-existent natural

is death to a mother somewhere in the world every minute, as
documented by the World Health Organisation.
Where you go from here depends upon the response of the woman.
If she still refuses and seems unlikely to agree with the medical
approach, then as a matter of principle, you should support her
with the decision, but offer all assistance if a haemorrhage were to
occur, as there is usually nothing to be gained by arguing with such
a patient.
Some perceptive patients may have been mischievously misled
by other health professionals and reasoned argument is possible,
but there is an imperative NOT to force a decision at the initial
consultation. Place the facts on the table for further discussion at a
later time.
t: (03) 9412 2912

e: sols@ranzcog.edu.au
w: www.ranzcog.edu.au/sols/index.shtml
The Specialist Obstetrician Locum Scheme (SOLS) is funded by the Australian Government
The College
Fetal Surveillance:
A Practical Guide
On behalf of the FSEP team, RANZCOG and Southern Health, we are pleased to announce the launch
of the handbook, Fetal Surveillance: A Practical Guide. This book is the result of a partnership between
the RANZCOG FSEP and the Maternal Fetal Medicine Unit at Monash Medical Centre, Southern Health
in Melbourne.
The book acts as a stand-alone resource, supports the face-to-face and web-based components of the
program (OFSEP) and integrates with the RANZCOG Intrapartum Fetal Surveillance Clinical Guidelines.
The book costs A$35 (including GST) plus postage. Order forms are available on the FSEP website or
via the FSEP Administrator.
The RANZCOG Fetal Surveillance Education Program (FSEP) is a
highly successful education program, run on a cost-recovery basis,
with workshops delivered throughout Australia and New Zealand
and now in Europe. The FSEP currently provides education to over
150 hospitals and the FSEP programs have been delivered to over
13,000 clinicians. There is a high demand for ongoing education
and participant feedback following the sessions continues to be
consistently positive.
Fetal Surveillance: A Practical Guide adds another dimension to our

education program and is designed to be an easy-to-read resource
for all clinicians involved in the care of women in pregnancy and
labour.
The authors have strived to keep the handbook short and clinically
focused. As with the RANZCOG Fetal Surveillance Education
Program (FSEP) and the Online Fetal Surveillance Education
Program (OFSEP), a solid understanding of fetal physiology
underpins the clinical application of knowledge. In this way, it is
believed that clinicians will be better equipped to interpret and
manage the diverse fetal heart rate patterns that they will encounter
in their daily work. Contents include the physiological basis for
fetal surveillance, fetal heart rate monitoring, the normal CTG, the
abnormal CTG and other methods of fetal surveillance, including
Doppler assessment.
The FSEP also offers an online program (OFSEP), designed
specifically to complement the range of face-to-face programs the
FSEP offers. The program is easy to use and can be accessed from
work or home. Importantly, the OFSEP is an evolving resource,
completely under our control, that will continue to be updated
and expanded as required. The OFSEP is offered free to those
institutions using the FSEP face-to-face education programs.
Of primary importance to the future of the FSEP is the development
of a valid and reliable tool to assess competency in fetal
surveillance across all clinical groups. The FSEP is developing such
a tool, with the assistance of the Assessment Research Centre in the
Faculty of Education at the University of Melbourne.
Videoconferencing of the refresher program, following a successful
trial, can now be provided to remote rural sites at a significantly
reduced cost.
54 O&G Magazine
The FSEP is ultimately aiming to provide a cost-effective suite

of products, targeted specifically to meet the learning needs of
clinicians across Australia and New Zealand. Of equal importance
is the need to address the risk management requirements of
participating institutions in the area of fetal surveillance.
For further information regarding the publication, Fetal Surveillance
A Practical Guide, or FSEP education please contact the FSEP
Administrator on:
(t) +61 3 9412 2958
(e) fsep@ranzcog.edu.au
(w) www.ranzcog.edu.au/fsep
The College
RANZCOG Practice Profile

Workforce Survey
Dr Ted Weaver
FRANZCOG
Valerie Jenkins
Manager, Fellowship Sevices
Kate Lording
Twenty years ago, almost without exception, RANZCOG Fellows practised

in both obstetrics and gynaecology. When the College undertook workforce
planning, or was asked questions by a government department about
the numbers of obstetricians currently practising in the discipline, we
could have confidently used the number of actively practising Fellowsas a
reasonable approximation of the obstetric workforce.
Project Officer
Preliminary results of the 2009 practice profile indicate that only 63

per cent of current Fellows practise obstetrics and gynaecology, with
as many as 26 per cent practising gynaecology exclusively.
Over the past decade, the College has conducted workforce surveys
every three years, and while these surveys have given us a snapshot
of the Fellows activities, invariably the results have raised more
questions than they have answered. The results of the last workforce
survey were reported in O&G Magazine, Vol 8 No 3 Spring 2006.
Why develop a practice profile?
Workforce issues are of great concern to the RANZCOG and there
has been a paucity of data on the day-to-day work profile of the
Fellowship and their future practice intentions. The information
at the College is confined to demographic information (age,
gender, location and qualification), with no information on scope
of practice. In planning the O and G workforce for the future, it is
vital for the College to understand the current work profile of the
speciality. Consequently, Council approved the development of an
online practice profile.
In July/August 2009, all active Fellows were contacted by email
requesting them to complete the RANZCOG Practice Profile.
Those with no known email address, despite being a Council
requirement for Fellows to have one, were contacted by post and
asked to go online and complete their profile. To date, less than
half of the Fellowship has responded (46.5 per cent). This is a very
disappointing result. It is essential that all Fellows complete the
survey so that the College has an accurate snapshot of the practice
profile of the Fellowship. These data will also be provided to
regional committees and the Provincial Fellows Committee to inform
them on the profile of their colleagues and enable comparison
between Australia and New Zealand, and within Australia.
Table 1.
2006 Workforce Survey 2009 Practice Profile
% Female Fellows 28%
35%
Aged 60 years
or older
20%
25%
The full age/gender distribution of the 2009 Practice Profile

respondents is detailed in Table 2. Overall, the Fellowship is still
predominantly male (65 per cent), however, Fellows under the age
of 50 are now more likely to be female.
Table 2. Age by gender
Age group
Female
Male
Total
<40
9.7%
5.0%
14.7%
40-49
14.7%
15.9%
30.6%
50-59
8.5%
20.7%
29.2%
60-69
1.7%
20.0%
21.7%
70+
0.1%
3.7%
3.8%
Total
34.7%
65.3%
100.0%
As mentioned in the introduction, it is no longer true that 100 per

cent of the Fellowship practises both obstetrics and gynaecology.
Significantly, 26 per cent of Fellows report that they are only
practising gynaecology (see Figure 1).
Figure 1. Scope of practice.
obstetrics only
10%
no response
2%
Confidentiality
Some may be concerned about the confidentiality of the data. As
with all College information, confidentiality is assured. Only deidentified data will be reported or published.
Preliminary results of 2009 practice profile
Please note that the following information is based on the responses
of 776 Fellows; a response rate of only 46.5 per cent of the
Fellowship.
The increasing feminisation and ageing of the workforce continues,
as can be seen in a comparison of gender and age data from the
2006 Workforce Survey and the current Practice Profile responses
(see Table 1).
gynaecology only
26%
both obstetrics and gynaecology

63%
The College
The nature of practice (Table 3) is interesting, with 50 per cent of
the Fellowship practising in both the public and private sector. Table
4 shows that a higher proportion (32 per cent) of female Fellows
practise only in the public sector, compared with 25 per cent of
male Fellows. Females are almost twice as likely as males
to practise only obstetrics.
Table 3. Nature of practice
Nature of practice
Fellows
Private only
173
22%
Private and public
387
50%
Public only
216
28%
Total
776
100%
Both obstetrics
and gynaecology 9.7%
Gynaecology
only
9.3%
Public
only
Total
27.9%
20.0%
57.6%
13.4%
3.7%
26.4%
0.4%
1.1%
0.4%
1.9%
Obstetrics only
1.5%
4.5%
8.1%
14.1%
20.9%
46.9%
32.2%
100.0%
34.5%
18.7%
65.2%
13.6%
2.0%
25.1%
Both obstetrics
and gynaecology 12.0%
Gynaecology
only
9.5%
Male
Private/
public
No response
Female Female subtotal
No response
0.6%
1.2%
0.4%
2.2%
Obstetrics only
1.0%
2.2%
4.3%
7.5%
Male subtotal
23.1%
51.5%
25.4%
100.0%
It is essential that all Fellows

complete the survey so that the
College has an accurate snapshot
of the practice profile of the
Fellowship.
Table 5a. Females in private practice
Total
56 O&G Magazine
10%
12%
6%
1%
29%
15%
29%
20%
7%
71%
25%
41%
26%
8%
100%
Table 6. Private practice hours

Private practice hours
worked per week
Fellows
00-20
171
30%
21-40
225
40%
41-60
139
24%
61+
36
6%
Total
571
100%
Table 7. Public practice hours

Public practice hours
worked per week
Fellows
00-20
316
21-40
151
41-60
141
60+
15
Total
623
The proportion of Fellows in solo private practice has remained high

at 68 per cent compared to 66 per cent in 2006. The following
tables provide a breakdown of the hours worked by Fellows in
private practice by nature of practice and gender. Males working
in the private sector are more likely to work in solo practice than
females, who are more likely to work in a group practice.
Females in group
private practice
Females in solo private
practice
Private practice hours worked per week

00-20 21-40 41-60
61+
hours
hours
hours
hours
Total
Overall, 30 per cent of respondents work more than 40 hours

per week in private practice compared with 25 per cent in public
practice (Tables 6 and 7). Further analysis is required to report the
number of hours spent in both public and private practice by gender
and nature of private practice.
Nature of practice
Private
only
Males in group private

practice
Males in solo private
practice
Total
Table 4. Gender and scope of practice
Scope of practice
Table 5b. Males in private practice
Private practice hours worked per week

00-20 21-40 41-60
61+
hours
hours
hours
hours
Total
15%
17%
6%
1%
39%
18%
23%
17%
3%
61%
33%
40%
23%
4%
100%
%
51%
24%
23%
2%
100%
Of those responding, 69 per cent indicated that they used

ultrasound in their practice.
Fellows practising private obstetrics indicated that, on average, they
delivered 149 babies annually, with solo practitioners more likely to
have a higher delivery rate.
Table 8. Private deliveries
Nature of private
practice
Deliveries per
year (mean)
Group
125
Solo
159
No response
30
Overall
149
Future practice intentions

It is of concern that of the 291 (38 per cent) Fellows who have
indicated that they are currently performing private deliveries, 52
per cent intend to decrease their obstetric practice over the next
five years, while only 18 per cent intend to increase their obstetric
numbers, leaving a considerable short-fall in the available private
obstetric workforce.
The College
Table 9a. Estimate of private deliveries in two years

Fellows
Table %
Same as 2009
131
45%
Decrease
102
35%
Increase
58
20%
Total
291
100%
CPD Self-Education
Activities
Table 9b. Estimate of private deliveries in five years

Fellows
Table %
Same as 2009
87
30%
Decrease
151
52%
Increase
53
18%
Total
291
100%

The outlook in the public system is similar, with 28 per cent of

those who indicated that they are currently performing intrapartum
obstetrics planning to cease obstetrics within five years (Table 10b).
Table 10. Current obstetrics public
Current Obstetrics Public Fellows
Antenatal care
32
Antenatal and
intrapartum care
364
Intrapartum care
64
Total
460
Table %
7%
79%
14%
100%

Table 10a. Two-year intention public intrapartum obstetrics

Current Obstetrics Public No response No
Yes
Antenatal care
0%
4%
3%
Antenatal and
intrapartum care
2%
6%
71%
Intrapartum care
0%
3%
11%
Total
2%
13%
85%
Table 10b. Five-year intention public intrapartum obstetrics

Current Obstetrics Public No response
No
Yes
Antenatal care
0%
5%
2%
Antenatal and
intrapartum care
0%
21%
58%
Intrapartum care
0%
7%
7%
Total
0%
33%
67%
In this first practice profile, the focus was on obstetrics. In the future,
the profile will be expanded to explore the future practice intention
of Fellows practising gynaecology and will include questions for
Fellows undertaking non-clinical practice.
If you have not yet completed your practice profile,
please do so now, by going to the Practice Profile page
on the College website: www.ranzcog.edu.au/fellows/
PracticeProfile.shtml .
Matrix of gynaecological practice

Table 11 displays the various aspects of gynaecology that the
Fellows indicated they practice in both public
and private sectors.
What is next?
This report provides a brief snapshot of the
data from the practice profile. Further analysis
will be undertaken once the response rate has
increased.
It is important that all active Fellows complete
their practice profile. It is only then that
the College will have a true profile of the
Fellowship. A Diplomates profile is currently
under development.
Data will be made available to regional
committees and the Provincial Fellows
Committee on the practice profile of the
Fellowship in their region.
Table 11. Gynaecology practice public and private

Private
Private office operative
Private
Private
Private Private
gynaecology gynaecology colposcopy ultrasound IVF
urodynamics Total
Public
office
gynaecology 150
Public
operative
gynaecology 173
Public
colposcopy 110
137
129
65
21
21
523
168
154
84
21
26
626
102
110
51
12
15
400
Public IVF
7
Public
urodynamics 19
32
19
15
13
74
Total
433
413
212
61
77
459
Medico-legal
Informed consent in labour

Australian perspectives
Andrew Took
Avant National Manager
Member Advisory Service

Australia
The general rule is that a medical practitioner must not undertake medical
procedures on patients without their informed consent.1 On some occasions,
in obstetric practice it will be impossible to obtain a valid consent due to the
clinical status of the patient.
It would be nonsensical (not to mention unethical and unlawful)

on the basis of an absence of express consent not to provide
emergency life-saving treatment to an unconscious patient. The
common law has long recognised a defence of necessity to justify
medical practitioners providing treatment in an emergency without
first obtaining the patients consent. In addition, in most States and
Territories2, there is also legislation which allows treatment in an
emergency to be given without consent to save a patients life or
to prevent serious damage to the patients health. In both cases, to
rely upon the necessity defence or legislation, the treatment must
be required urgently and not for reasons of medical convenience.
In the second stage of labour, the capacity of a patient to
understand the implications and alternatives to a proposed
intervention varies. If antenatal education had adequately informed
the patient of the facts concerning vacuum delivery or other possible
matters during delivery, then the issue of varying capacity during the
procedure is of lesser moment, as the obstetrician may rely upon the
pre-delivery information given to the patient when competent.
However, in a significant number of instances, no such pre-emptive
discussion takes place, or the patient may not be previously known
to the attending obstetrician. Obtaining valid consent in these
circumstances may be problematic depending on the patients
cognitive capacity to understand the general nature and effect
of proposed vacuum delivery. Providing an explanation of the
procedures material risks, such that the patient is capable of
understanding the treatments implications, may again be equally
problematic. The content and extent of the consent process will
reflect the practitioners assessment of the patients capacity.
If patient competency is judged to be absent, the alternatives of
proceeding by way of substitute consent, or proceeding by way
of no consent and relying upon the defence of necessity become
options. All States and Territories have legislation providing for
substitute consent to be given to treatment of adults who lack
capacity to consent on their own behalf. In New South Wales for
example, if a person over the age of 16 is incapable of giving
consent3, a person responsible4 may consent to treatment on
behalf of the patient.
Bearing these legal issues in mind, the clinical realities are:
The effect of labour pain and narcotic administration may render
the usual consent process unworkable.
However distressed the patient is, it is important to provide a
short explanation of what is proposed. The patients partner, if
present, should be involved.
There is legislative and common law recognition of your duty to
provide the assistance required by mothers and babies, even if
consent is impossible.
An obstetrician should endeavour to ensure that patients are
educated during the antenatal period about interventions that
may be required during labour and delivery.
58 O&G Magazine
This education, together with good rapport, will assist in the

consent process and minimise the likelihood of a complaint or
allegation concerning inadequate consent.
Always document points mentioned or discussed with the patient
in the medical record.
References and notes
1.
2.
3.
4.
Avant Members Area, Registrars Toolkit, p48: www.avant.org.au2.

See for example New South Wales Guardianship Act 1987.
New South Wales Guardianship Act 1987.
Person responsible is defined in order as:
The patients guardian
The patients spouse, if the relationship is close and continuing
The patients carer
A close friend or relative of the patient.
CPD Self-Education
Activities

Medico-legal
Fleur Dewhurst
Medico-legal Advisor
Legal Unit
Royal Hobart Hospital

Tasmania
There is little doubt that medical practitioners must obtain a patients consent
prior to an interventional medical procedure. For those practitioners providing
care to patients in labor who require an instrumental delivery, the practical
question becomes, what steps should be taken by the medical practitioner to
obtain that consent?
Should the consent be verbal or should a written consent form be

used and from a medico-legal perspective, what is the best time
to secure that consent? Is it sufficient to secure the consent at the
bed-side prior on the labour ward, or is it appropriate to secure
the consent prior to delivery in the outpatient clinic or in the private
rooms? This article will provide an overview of the medico-legal
requirements for medical practitioners obtaining patient consent,
and discuss some of the medico-legal and practical considerations
that should be taken into account by medical practitioners prior to
obtaining consent for an instrumental delivery.
For a patients consent to be considered legally binding, the
medical practitioner is required to advise the patient, in broad
terms, the nature of the procedure and the risks associated with
that procedure. There is similarly a requirement that the information
is provided in language that the patient understands and that
information is provided at a time when the patient is free from
duress. A patient who is not informed in broad terms of the nature
of the procedure which is intended may bring a common law action
against the medical practitioner in trespass.1
A medical practitioner also has a general duty of care to provide
information to a patient that includes an explanation of the material
risks associated with that procedure. The information provided
should be of a quality to allow the patient to weigh the risks of
proceeding with a certain procedure and provide the patient with
an opportunity to ask questions relating to the risks associated with
that procedure. A patient who does not receive information, or
receives information of an insufficient quality, may bring a common
law action against the medical practitioner in negligence, or refer
the practitioner to the appropriate medical registration body for
investigation and potential prosecution.
What then is the most effective process for the medical practitioner
to secure patient consent and satisfy medico-legal requirements?
It is true that consent does not need to be in the written form to be
valid.2 Verbal consent can be taken from the patient and there is an
argument that verbal consent promotes the communication between
the medical practitioner and patient. Practically, the benefits of
obtaining verbal consent from the patient are that consent can be
obtained in the delivery room prior to any instrumental delivery.
However, verbal consent may be problematic in that verbal consent
often lacks sufficient documentary detail of the discussion held
with the patient and insufficient detail with respect to the quality
of information provided to the patient. Any enquiry made by a
civil court or registration board will include an analysis of the
written record. This may prove to be problematic for the medical
practitioner.
Conversely, the medical practitioner may choose to have the
patient sign a written consent form. The consent form may be a
generic consent form or it may be designed as a procedure specific
consent form that includes a full explanation of the procedure,
often with illustrative diagrams, and an explanation of the risks
associated with instrumental delivery. The benefits of the procedure
specific form are that it can be used in clinic or the delivery room
and, if used correctly, the consent form can be used as a prompt
for the clinician to discuss issues in sufficient detail. Once the
patient signature is obtained on the consent form, this will provide
documentary evidence should a claim be made against the medical
practitioner in a civil court or professional tribunal. However, it

may also provide a disservice to the medical practitioner in that the
medical practitioner may substitute verbal communication by simply
providing the procedure specific form. The fact that a patient has
signed a consent form is prima facie evidence of patient consent,
but it is not conclusive evidence that consent has been obtained.3
Courts will review the process of communication and provision of
information to decide if consent has been obtained.
For a patients consent to be

considered legally binding, the
medical practitioner is required
to advise the patient, in broad
terms, the nature of the procedure
and the risks associated with that
procedure.
Regardless of the method of obtaining consent, a further
consideration for the medical practitioner is when should the
consent be obtained and what medico-legal impact, if any, does
timing have. For many medical practitioners, practically, the best
time for obtaining patient consent may be in the delivery room
prior to proceeding with the instrumental delivery. The medical
practitioner is in a position to fully assess the clinical progress of the
delivery and provide the patient with accurate contemporaneous
information on the progress of the delivery and discuss what steps
need to be taken to perform the instrumental delivery. However, in
many cases, the patient may have been labouring for an extended
period of time, maybe hours, and can be tired, distressed and in
pain.
What effect does exhaustion, distress and pain have on the validity
of a patients consent? While the author could not find any
Australian decisions directly on this issue, it is evident that courts
are taking a fairly pragmatic view on the patients right to provide
consent in an environment free from duress and consider and weigh
all information provided. In a recent unreported decision of the
New South Wales Court of Appeal4, the court found that an adult
patient should be in a position, when providing consent, to make
a choice and have the right to elect on what treatment options are
acceptable.
Similarly, there is evidence that courts are placing a high standard
on medical practitioners to discharge their duty with respect to
the quality of information provided to patients during the consent
process. In a recent failed sterilisation case, decided in the South
Australian District Court5, the court imposed an obligation on a
gynaecologist to provide information and discuss not only their
personal sterilisation failure rate, but also to provide a comparison
with respect to the published literature on failure rates. In addition,
in a recent case decided in the Western Australian Court of Appeal6,
the court was highly critical of the failure of a gynaecologist to
spend sufficient time with a patient to discuss a procedure, the risks
associated with that procedure, and to discuss those risks in a way
that could be understood by the patient.
Medico-legal
...consent can be obtained for

an instrumental delivery in a
number of ways. It can be obtained
verbally prior to delivery or it can
be obtained by the use of a written
consent form in the outpatient clinic
prior to delivery.
Ideally then, patients who attend clinics or private rooms prior to
delivery can be consented for the prospect of instrumental delivery.
The medical practitioner can take the time to discuss the details
of the procedure and the risks associated with that procedure.
Where practicable, literature can be provided to the patient for
consideration and this will allow the patient time to consider the
information provided and ask questions where required. During
this consultation the discussion with the patient can be documented
in the patient record and a consent form signed. This will provide
the medical practitioner with a sufficient record should any claim
be made. However, the author acknowledges that in a public
hospital or busy private practice this may provide some practical
and logistical difficulties. Depending on the circumstances, it may
be that the medical practitioner who obtains consent from the
patient in this situation is not the medical practitioner performing the
instrumental delivery.
In summary, consent can be obtained by the medical practitioner
for an instrumental delivery in a number of ways. It can be obtained
verbally prior to delivery or it can be obtained by the use of a written

consent form in the outpatient clinic prior to delivery. Whatever
method is chosen by the medical practitioner, courts will inevitably,
in their review of any matter before them, assess on the facts, the
quality of the consent process used by the medical practitioner.
The medical practitioner should be cognisant of the medico-legal
issues and consideration should be given to a correct assessment
of the patient and the provision of quality information on the
procedure and risks associated with the procedure. Similarly, a
consideration for the medical practitioner is the timing of when
the information is provided, to ensure the patient has the ability
to understand what is being put to them, enabling the patient to
make an informed decision. The author recommends that the most
effective method for obtaining consent is in the outpatient clinic or
private rooms prior to delivery. This will enable sufficient time for
both practitioner and patient to discuss the procedure in a relatively
stress-free environment and the patient to receive appropriate
literature for consideration. A procedure specific consent form can
be used and signed by the patient and kept in the patient file as
evidence of a contemporaneous record.
References
1.
2.
3.
4.
5.
6.
Rogers v Whitaker (1992) 175 CLR 479.

Re T (1992) 4 All ER 649at 653.
Chatterson v Gerson (1981) 1 All ER 257.
Obrien v Wheeler (1997) New South Wales Court of Appeal
Unreported.
G&C v Down (2008) SADC 135.
Hassan v The Minister for Health [No 2] (2008) WASCA 149.
New Zealand perspective

Denys Court
Medico-legal Consultant
Medical Protection
Society (MPS)
Informed consent for interventions in labour requires a voluntary choice by a

competent woman who has received and understood sufficient information. In
labour, with its attendant pain, medication, exhaustion and a sense of duress,
how can obstetricians avoid complaints in striving to meet this standard?
The legal principles of informed consent which developed over time

in many common law jurisdictions are, in New Zealand, enunciated
in the Code of Health and Disability Services Consumers Rights (the
Code)1 which provides the right to make an informed choice, give
informed consent, refuse treatment or withdraw consent.2
Informed consent may be considered to be the making of a
voluntary choice by a competent individual who has received and
understood sufficient information. In labour, however, although
decision-making capacity will usually be maintained, it may be
compromised by the labour itself, adding duress to the environment,
especially if the woman is experiencing unrelieved pain, or there is
an emergency. Furthermore, narcotic analgesia may compromise
competence.
It must also be remembered that rights to consent are restricted
to the woman herself, the fetus having no individual legal rights
until birth. Therefore, obstetricians cannot take actions in the best
interests of a fetus without the consent of the mother. Likewise,
in emergency circumstances, although involving the partner in
discussions prior to decision-making is appropriate, a partner
has no right to consent on behalf of the woman in emergency
circumstances where competence is compromised.
60 O&G Magazine
These realities underline the need for provision of information

during the antenatal period and discussion at that time of the range
of choices that may need to be faced in labour. Obstetricians
typically delegate much of this obligation to antenatal classes, but
where there is the opportunity to test a womans understanding prior
to labour (as with private patients), it is prudent to do so.
A fundamental question is: what constitutes sufficient information
in a consent process? The Code provides that every consumer has
the right to the information that a reasonable consumer, in that
consumers circumstances, would expect to receive.3 Thus, there are
two parts to this question. Firstly, what would a reasonable person
want to know in making this decision; and secondly, what other
information does this person want to know that they will rely on in
making their decision? The first part is the information that you and
your colleagues would normally be aware as being important to
the making of the decision what you always (or should always) tell
patients. The second part can be satisfied by asking patients what
else they want to know in order to make the decision (at least: Is
there anything else you want me to explain?). It is also prudent to
test their understanding (at least: Is there anything I have told you
that you dont understand?).
Medico-legal
In avoiding complaint or allegation of insufficient information,
two things are protective to the obstetrician. Firstly, documenting a
summary of the information; and secondly, the existence of rapport.
If rapport is poor (as when the obstetrician has not met the woman
until the need for an urgent decision), documentation should be
more detailed.
It is sobering to remember that an obstetrician has been found in
breach of the duty to provide sufficient information, though this
involved information relevant to curettage for secondary postpartum
haemorrhage, where the well-recognised risk [of perforation] when
exploring the uterus in this context should have been discussed
despite being a less than one per cent risk.4 The house officer who
obtained written consent was not found liable for the obstetricians
failure to provide sufficient information.
Finally, if an emergency in labour does render the woman
incompetent to make informed decisions, the Code allows health
professionals to provide services where it is in the best interests of
the patient; and reasonable steps have been taken to ascertain the
views of the patient where possible.5
References
1.
2.
3.
4.
5.
http://www.hdc.org.nz/theact/theact-thecode .
Right 7 of the Code.
Right 6 of the Code.
http://www.hdc.org.nz/opinions%20(98HDC19009) .
Right 7(4) of the Code.
RANZCOGs statement, C-Gen 2: Guidelines for

Consent and the Provision of Information Regarding
Proposed Treatment, is currently being revised and
will be published in O&G Magazine in 2010.

subject indexes.
indexes useful!
Thinking of retiring from

active practice?
If or when you do retire will you be:
Completely and permanently retired from practice as a
specialist obstetrician and/or gynaecologist?
No longer acting as an expert witness in the field of
obstetrics and gynaecology, except in:
cases for which you have already provided an opinion
prior to the date of signing this Retirement Declaration; and
cases which deal with medical practices current during any
time you were in active practice as a specialist obstetrician
and/or gynaecologist and prior to signing the Retirement
Declaration?
If you answered YES to all of the above then why not download
the Retirement Declaration form:
www.ranzcog.edu.au/fellows/cpdretirement.shtml .
What happens to my Fellowship if I sign the Declaration of
Retirement form?
If or when you decide to sign and submit the completed
Declaration of Retirement form to RANZCOG, your classification
will be changed to Retired Fellow.
As a Retired Fellow of RANZCOG you will not have to:
Pay annual subscription fees
Participate in the RANZCOG CPD Program
As a Retired Fellow you will still receive the following from the
College:
O&G Magazine (four issues per year)
ANZJOG (six issues per year)
Journal of Obstetrics and Gynaecology Research
(if you have elected to receive this)
RANZCOG Annual Report
What about my patient records?
See College Statement No. WPI-8 on Guidelines for Patient
Record Management on the Discontinuation of Practice: www.
ranzcog.edu.au/publications/collegestatements.shtml#WPI .
What if I dont want to retire just yet?
If you are not in a situation where you can complete the
Retirement Declaration form then you will continue as a Fellow
of the College.
For further information or a copy of the Retirement Declaration
form, please contact:
Val Spark
(t) +61 3 9412 2921
(e) vspark@ranzcog.edu.au
Applications invited for new
Examiners
Fellows and Diplomates of the College are invited to apply for membership of the
Colleges Board of Examiners.
RANZCOG has only one Board of Examiners from which the Diploma, Membership and Subspecialty
Examiners are drawn for each relevant written and oral examination.
There is a Provisional Examiner process that must be followed prior to elevation to the Board of Examiners.
Both Diplomates and Fellows may examine at DRANZCOG level.
Fellows may examine at MRANZCOG level and, if they are currently working in a
subspecialty discipline, they may also examine at subspecialty level.
Duties
Members of the Board of Examiners may participate in the following activities related to the components of their respective
examination level:
1.
Developing new stations for the oral examinations. This consists of generating initial case summaries and working on the
development of cases submitted by other examiners.
2.
Participating in oral examinations. This involves participation in a pre-examination workshop immediately before each examination as
well as participation in the examination itself, either as an examiner or an observer.
3.
Developing new multiple choice questions for the written examinations. This involves writing new questions and/or editing questions
submitted by others.
4.
Participating in the standard setting panel for the written and oral examinations. This involves working through all of the questions
and cases used in an examination and estimating the difficulty of each question.
In addition, Fellows examining at MRANZCOG and Subspecialty level may participate in the following:
5.
Developing new short answer questions for the written examination and marking short answer question papers. This involves writing
new questions and/or editing questions submitted by others and the assessment of candidate responses against a pre-determined
marking scheme.
Additional information
Availability
Examiners are expected to be available at least once a year for their designated level examinations.
Qualifications and Experience
Applications for Membership/Subspecialty must be actively engaged in clinical practice in the speciality. Applicants must be familiar with
the current training programs but need not hold an appointment in a teaching hospital. Previous experience in examining at undergraduate
and/or postgraduate level is preferred.
Method of Application
To be considered for an appointment, an application must be submitted to the Education and Assessment Committee. The application
form may be obtained from the Assessment Services department at College House by calling +61 3 9417 1699 or by downloading from the
College website at www.ranzcog.edu.au/fellows/examiners.shtml . A current curriculum vitae must accompany a completed application
form. Contact details for two referees must also be provided.
Review of Applications
Applications will be reviewed by the RANZCOG Education and Assessment Committee three times a year (March, July and November).
Applicants will be notified in writing of the result of their application.
Enquiries
Questions regarding application for membership or the duties of examiners should be directed to Frances Gilleard, Assessment Coordinator,
Assessment Services, on +61 3 9412 2945 or at fgilleard@ranzcog.edu.au .
The College
MRANZCOG Written Exam

February 2009
Dr Jolyon Ford
MRANZCOG SAQ Coordinator

The short answer questions (SAQ) are designed to test not only the
candidates knowledge, but also their ability to apply this knowledge
to typical higher order thinking that is used in everyday obstetric
and gynaecological practice. While some questions simply require
candidates to list investigations, diagnoses or treatments, others
will ask for evaluation, prioritisation, comparisons, or justifications
for certain treatments or assessments. Examples of this include the
ability to apply evidence or guidelines to unusual clinical situations,
or to be able to evaluate the benefits and disadvantages of different
treatments.
Rather than responding with a standard list of investigations or
treatments, candidates are advised to consider these in the context
of the clinical information provided. Candidates should also pay
careful attention to what the question is asking them to do. For
example, a request to justify treatments of a case should include the
rationale for why that treatment should be considered, rather than
simply list treatments that are available.
This year the Examination Assessment Committee agreed to provide
the whole question to candidates to assist them in their preparation
for the exam. This also means that questions are less likely to be
repeated in future exams, although the curricular topics may be
used as a basis for any future questions. Candidates should review
the written information provided on the RANZCOG website for
more information on the format of the exam.
What follows is a full transcription of the exam and a few notes to
outline the expectations from each question.
1. Hyperemesis gravidarum
a. List the clinical features needed to make a diagnosis of
hyperemesis gravidarum.
b. List the potential maternal complications of moderate/severe
hyperemesis.
A 19-year-old primigravida is admitted at 11 weeks gestation
with intractable vomiting that has persisted over the previous five
weeks. She has no previous history of any medical problems.
On examination she is clinically dehydrated and tachycardic.
Examination is otherwise normal. Blood has been sent for full blood
count, urea and electrolytes, liver function tests and thyroid function
test. The results from these are within normal limits except for:
Na 125 mmol/L
(normal 135-145 mmol/L)
K 3.1 mmol/L
(normal 3.5-5.0 mmol/L)
Urea 6.8 mmol/L
(normal 2.5-6.7 mmol/L)
TSH 0.2 mU/L
(normal 0.5-5.7 mU/L)
Free T4 25 pmol/L
(normal 11.0-22.9 pmol/L)

c. Outline how you would manage this patient.
This is a common condition that should be familiar to all

candidates. Biochemical thyroid derangement is a common
association and does not require investigation or treatment unless
symptomatic or persistent. Management should also include a
strategy if more common treatments are unsuccessful.
2. Ethics of homebirth/vitamin D deficiency in
pregnancy
A multiparous 25-year-old Somali woman presents to your
antenatal triage clinic, accompanied by her independent midwife.
She traditionally wears a burkha when outside. She is now 15 weeks
pregnant and her midwife has already arranged routine pregnancy
investigations, as well as vitamin D screening. She is also requesting
a homebirth and wishes your antenatal team to provide hospitalbased backup.
Question 1
a. What are the appropriate screening measures for vitamin D
deficiency? How would you interpret vitamin D levels and
clinically manage this woman regarding her vitamin D status?
b. What are the risks to the mother and the baby of vitamin D
deficiency?
Question 2
a. Discuss the ethical principles that should be followed in the
context of giving advice to a woman requesting homebirth.
b. List four arguments against homebirth and four arguments
supporting homebirth.
A greater understanding of the consequences of vitamin D
deficiency make this a topical question and many units now have
policies regarding screening. General principles of screening,
supplementation and retesting were required. Core ethical principles
(such as beneficence, non-maleficence, equality and justice) were
expected as the basis for discussion about homebirth, with an ability
to demonstrate an understanding of the benefits and risks.
3. Infertility and laparoscopic anatomy
Mr and Mrs Carmichael present with a two-year history of primary
infertility. The baseline fertility investigation results are normal.
a. List the relative advantages and disadvantages of
hysterosalpingography in the further investigation of this
situation.
b. List the relative advantages and disadvantages of a hysteroscopy,
laparoscopy and dye studies procedure in the further
investigation of this situation.
c. Mrs Carmichael elects to undergo a hysteroscopy, laparoscopy
and dye study procedure. A periumbilical Veress needle entry
technique is utilised. What tests are available to check for correct
placement of the Veress needle?
The College
d. Which artery is most commonly at risk of damage during the
placement of a low lateral secondary port?
e. Briefly describe the anatomy of this artery and the practical steps
that can be taken to avoid injury to this vessel.
An ability to balance the benefits and disadvantages of two
common methods for assessing tubal patency was expected. Safe
access to the abdomen is an essential part of laparoscopic surgery
and candidates were expected to have a detailed understanding
of techniques used to avoid harm and damage to the inferior
epigastric artery.
4. Malpresentation and abnormal progress in labour
a. What constitutes abnormal progress in the active phase of the
first stage of labour?
b. What are the causes of slow progress in labour?
c. What are the delivery options for a woman at full dilation with a
face presentation at term?
A 34-year-old woman (G2, P1 SVD at term) is transferred from
primary care at term +10 days following spontaneous rupture of
membranes 18 hours ago and the onset of regular contractions
over the last six hours. On admission, the vertex was presenting
and the head was 3/5 palpable abdominally. The cervix was 50 per
cent effaced and 5cm dilated with poor application of the head to
the cervix. Four hours later she is 6cm dilated, with the head 2/5
palpable; the position is direct occipito-posterior.
d. Justify your management of delayed progress in the first stage
of labour associated with an occipito-posterior position in this
multiparous woman?
A number of definitions are used internationally for slow
progress. WHO or NICE definitions or similar were accepted. The
management of delayed progress and abnormal presentation are
described in standard texts. The key word in the final part of this
question was justify. Candidates who did not explain briefly why
they would consider each management option to be appropriate
were unable to obtain full marks. A discussion about the controversy
around syntocinon use in this context was expected.
5. Maternal collapse
A 29-year-old woman, G2 P2 33 weeks gestation with one previous
caesarean section, presents with a sudden onset of breathlessness
and collapse. On arrival she is pale and pulseless but her ECG
shows normal electrical activity.
a. What are the possible causes of pulseless electrical activity in this
patient?
b. Prioritise your initial management of this patient.
c. After five minutes of resuscitation she shows no sign of
improvement. You are considering a perimortem caesarean
section. Describe, with justification, the steps taken to perform
this procedure.
The management of pulseless electrical activity (PEA) is part of the
management of a collapsed pregnant woman, but some of the
causes (such as hypothermia) are clearly unlikely in this case. Again,
a response in the context of the clinical scenario was expected.
Higher order functioning was tested in parts b and c with

candidates not only being expected to list management processes,
but to apply prioritisation to the management of a maternal
collapse. Justification was required for each step of a perimortem
caesarean section why each step is done the way it is done, such
the absence of the need for anaesthesia.
6. Menorrhagia
a. Why is normal menstruation self-limiting?
b. By what methods can menstrual loss be objectively assessed?
c. What is the mechanism of action of tranexemic acid in
menorrhagia?
d. Summarise the advantages and disadvantages of Mirena
(LNG-IUS) as compared to endometrial ablation procedures in
the management of menorrhagia.
Menorrhagia is one of the commonest conditions we see in
womens health. A high level of knowledge was expected. An
understanding of the normal physiology and pathophysiology
behind common conditions is expected, but was not well understood
by some candidates.
7. Pre-pregnancy counselling
A 32-year-old nulliparous woman seeks your advice for prepregnancy counselling. She has essential hypertension which was
previously thoroughly investigated and is now well controlled on
an ACE inhibitor. Her partner has a brother severely affected by
classical cystic fibrosis. Her body mass index (BMI) is 42 and blood
pressure is 135/85. She has had no other medical problems.
a. List the possible effects that her BMI could have on her fertility
and pregnancy.
b. What advice would you (or a medical geneticist) give regarding
her concern of having a child with cystic fibrosis?
c. What other steps would you recommend prior to pregnancy?
Much has been written on the effect of raised BMI on pregnancy
and the increasing frequency with which we are encountering this
issue makes this very relevant. Candidates could score points for
up to 14 different effects. Cystic fibrosis is a common autosomal
recessive condition and candidates were expected to demonstrate
the general principles of identifying the affected gene, counselling
the couple and arranging appropriate investigations. The final part
allowed candidates to describe both the general pre-pregnancy
counselling options and then those specific to this couple. Again,
application of information to the specific case was essential.
8. Recurrent miscarriage
a. Outline the theoretical immunological mechanisms in the mother
that allow implantation of the embryo to occur in normal
pregnancy.
A 39-year-old woman G3, P0 presents at eight weeks gestation with
an ultrasound demonstrating a non-viable fetus. She has had two
previous first trimester miscarriages.
b. Describe the relevant clinical features you would obtain from the
history.
64 O&G Magazine
The Royal Australian and New Zealand

College of Obstetricians and Gynaecologists
WANTED: VOLUNTEER FACILITATORS FOR

RANZCOG BASIC SURGICAL SKILLS WORKSHOPS
Fellows and Year 5 and 6 Trainees are needed to act as facilitators at the RANZCOG Basic
Surgical Skills (BSS) workshops conducted annually in each State in Australia and in New
Zealand. Attendance at a BSS workshop is compulsory for all Year 1 RANZCOG Trainees.
These practical, interactive two-day workshops are run on weekends and cover theatre
etiquette, handling instruments, knot tying, incision/closure, episiotomy repair, haemostasis,
electrocautery and stacks, hysteroscopy and laparoscopy.
Facilitators provide hands-on teaching and advice during the workshop and help with setting
up on the day. Time commitment: ONE weekend per year.
Applications and enquiries: Shaun McCarthy, Training Services Manager
tel +61 3 9412 2917, fax +61 3 9419 7817, email: smccarthy@ranzcog.edu.au
TRAINING FOR THE ADVANCED DIPLOMA OF O&G

(DRANZCOG ADVANCED)
ARE YOU A DRANZCOG HOLDER (a Diploma of O&G)?
Have you thought about upgrading your skills and doing the DRANZCOG Advanced training program?
The training program offers extended training for GP obstetricians who wish to:
manage complicated labours when they arise

perform LUSCS (Elective and Emergency) safely and confidently
provide support for GP obstetricians when specialist obstetricians are unavailable
perform laparotomies in emergency gynaecological situations
in special circumstances, be able to perform laparoscopies and/or colposcopies.
To obtain the DRANZCOG Advanced you need to:

undertake six months of supervised in-hospital training
complete the required number of clinical procedures as detailed in the DRANZCOG Advanced logbook
(which has to be checked and signed off by the relevant State Reference Committee Chair)
satisfactorily complete five written case studies, which have been assessed by the relevant State Reference
Committee Chair.
Further details and application forms can be found on the RANZCOG website at:
www.ranzcog.edu.au/trainees/diploma-trainees.shtml
The College
c. List the investigations you would offer the patient with a
justification for each.
c. Describe the information you will give her about starting and
taking the COCP.
Again, the underlying physiology behind common womens health

issues such as conception was required. The investigation of
recurrent miscarriage is well-described, but a brief comment on why
these investigations are justified was expected. What benefit is there
in knowing whether women have the conditions being investigated?
d. Apart from contraception, list other indications for prescribing

the COCP to a 14-year-old.
9. Soft markers on morphology screening in

ultrasound
A 30-year-old primigravida presents with the results of her routine
20-week morphology ultrasound. She did not have any form of first
trimester aneuploidy screening. The ultrasound reveals normal fetal
anatomy except for echogenic bowel.
a. What is the potential significance of echogenic bowel in this
20-week scan?
b. What other ultrasound features would you look for on this scan if
echogenic bowel was noted?
c. The woman is considering amniocentesis. What are the risks and
benefits of the procedure in this situation?
d. If fetal karyotyping is undertaken and excludes aneuploidy, what
other management, in addition to routine antenatal care, would
you undertake for the remainder of the pregnancy?
The management of the finding of echogenic bowel may vary
from no action at all, to further investigation depending on other
findings and risk factors. Causes other than aneuploidy should be
considered and investigation arranged if indicated. Candidates
should have a good working knowledge of amniocentesis.
10. Stillbirth
a. What is the Australian and New Zealand definition of stillbirth?
b. What is the approximate incidence of stillbirth in Australia and
New Zealand?
The key point here, other than the routine counselling prior to taking
the pill, is the age of the patient, which should trigger additional
lines of enquiry to exclude abuse and an additional risk of sexually
transmitted infection (STI). The justification in part b should allow
candidates to demonstrate how their standard management would
be altered when considering the patients age. Clearly, some
assessments (such as a Pap smear) would not be indicated and
others would be more important (such as STI screening).
12. Gestational trophoblastic disease
A 19-year-old woman is referred by the GP with vaginal bleeding
in her first pregnancy. The pregnancy is unplanned and of uncertain
gestation. Examination shows a 14-week size uterus. An ultrasound
arranged by the GP is strongly suggestive of a complete molar
pregnancy.
a. Outline the investigations required for this patient.
b. Describe the initial management and follow-up you would put in
place for her.
c. Histology confirms a complete molar pregnancy. How would you
counsel this woman about the cause of this?
d. What are the long-term risks of this and how are these
managed?
e. Her bHCG levels completely resolve after the affected
pregnancy. What are the implications of a molar pregnancy for
future pregnancies?
A full understanding of the management of trophoblastic disease
is important in reducing the risk of ongoing disease or recurrence.
Knowledge of the genetics and outcomes of these pregnancies is an
important part of patient counselling.
A 24-year-old woman presents in her first pregnancy at 34 weeks

gestation with absent fetal movements for the last 24 hours. The
midwife calls you as she is unable to find the fetal heart.
c. What is the management of suspected intrauterine fetal death in
this singleton pregnancy?
d. The investigations are all normal and therefore the stillbirth is
unexplained. Outline your management of this woman prior to
and during any future pregnancy.
Whilst it is fortunately uncommon, the management, investigation
and follow up of stillbirth should be known in detail by candidates.
11. The pill
A 14-year-old girl requests to start the combined oral contraceptive
pill (COCP) for contraceptive purposes.
a. What information would you require from her before prescribing
the COCP?
b. What examination and/or tests would you perform before
prescribing the COCP for this patient? Justify your answer.
66 O&G Magazine
Medical pamphlets
PO Box 24
Camberwell Vic 3124
ph: +61 3 9888 6262
fax: +61 3 9888 6465
The RANZCOG Fetal Surveillance Education Program

(FSEP) continues to deliver highly regarded fetal
surveillance education to healthcare professionals
in over 140 centres throughout Australia and New
Zealand. As a RANZCOG program, the FSEP is
not-for-profit and remains the leading cost-effective
CTG education provider in Australasia.
Our clinical content is of the highest quality,
comprehensively addressing fetal surveillance and
CTG use. Our popular face-to-face programs
facilitate adult learning whilst being time and
resource efficient.
We are continuing to develop our validated
competency assessment tool and have released our
online program (OFSEP) to support our face-to-face
programs.
We have published a fetal surveillance handbook to

act as an additional resource, as well as meeting
individual learning needs.
Our workshops are accredited with the
appropriate medical representative bodies and
attract RANZCOG PR&CRM points. Additional
PR&CRM points can also be earned by using our
straightforward audit tool.
We are currently taking bookings for 2010.

For further information or if you are interested in
booking or attending an education session, contact:
FSEP Administrator
(t) + 61 3 9412 2958
(e) fsep@ranzcog.edu.au
Do you have a RACOG Fellows gown

that you no longer need?
If so, the Image and Regalia Working Party would like to hear from you as they are keen to obtain RACOG Fellows gowns that are no
longer used by their owners. The aim is to build up the existing collection of gowns at the College. We plan to have the gowns available
for the use of members of Council, new Fellows being presented with their Fellowship and for hire by Fellows for special occasions
(a fee is charged for the hire of the gowns to cover postage and handling).
The gowns can be upgraded to a RANZCOG gown with the addition of silver braid.
The collection of gowns is kept in a special storage area and maintained in excellent condition.
The gowns are used by the Council members at every College function including Council meetings.
Any enquiries please contact:
Ros Winspear
Coordinator, Image & Regalia Working Party
ph: +61 3 9412 2934 fax: +61 3 9419 0672 email: rwinspear@ranzcog.edu.au
The College
SOLS Update
Valerie Jenkins
A contract worth A$3,000,000 has enabled the Specialist Obstetrician

Locum Scheme (SOLS) to increase support to rural specialists and GP
obstetricians.
Chair, SOLS Management Group
RANZCOG recently signed a contract for A$3,000,000 with the

Department of Health and Ageing (DoHA) to fund SOLS for a
further two years. This will enable SOLS to increase the number
of subsidised locum placements available to rural and remote
specialists and GP obstetricians.
SOLS Targets for 2009-2011
2009-10
Placements
Specialists
90
GP obstetricians 25
Total
115
Days
717
350
1067
2010-11
Placements
105
30
135
Days
840
420
1260
What does SOLS provide?

Eligible obstetricians can access the SOLS subsidised locum support
for 14 days and further unsubsidised support.
The SOLS model includes the following features:
A non-refundable administration fee of $600 (GST exclusive) per
applicant per year.
A daily locum fee subsidised to 50 per cent of the current market
rate of:
$2000 per day for 14 days (that is, @ $1000 per day) for
specialist obstetricians.
$1400 per day for 14 days (that is, @ $700 per day) for GP
obstetricians.
Payment of locum travel costs up to a total of $2000 per
applicant for both specialist obstetricians and GP obstetricians.
Payment of locum travel time to and from the placement, based
on the quickest means of transport available, at a rate of:
$500 per day to a maximum of $1000 per applicant for
specialist obstetricians.
$200 per day to a maximum of $400 per applicant for GP
obstetricians.
Priority will be given to those in a practice with either one or two
specialists in the public and/or private sector.
Organisation and payment of the locum medical registration fee
if required for the placement.
Organisation of additional Medicare Provider Numbers where
required.
What has SOLS achieved?
SOLS has achieved the following results over the past three financial
years:
1 July 2006 30 June 2007:
19 specialists received 174 days of locum support, with 156
days subsidised and 18 days unsubsidised;
1 July 2007 30 June 2008:
days subsidised and 149 days unsubsidised; and
1 July 2008 30 June 2009:
days subsidised and 213 days unsubsidised. GP obstetrician
scheme developed and introduced;
14 GPs obstetricians received locum support with 169 days
subsidised and 67 unsubsidised.
68 O&G Magazine
During the 2008-09 funding period, SOLS was able to fill 91 per
cent of advertised specialist placements and 81 per cent of GP
obstetrician placements.
SOLS needs more locums willing to travel to rural and
remote Australia to support obstetric colleagues. Why
not sign up for a locum placement and then follow that
with a holiday in a beautiful part of rural Australia?
You can participate in SOLS by undertaking a
locum position.
Following locum placements, 94 per cent of locums have indicated
that they would recommend doing a SOLS locum placement to
others. Many expressed the need to support their rural colleagues:
Any relief must be most welcome as these Provincial Fellows are on 24/7!
Great broadening experience.
Professionally satisfying and enjoyable.
Prevents burn out in rural and regional obstetricians.
SOLS locums are Fellows of RANZCOG or Diplomates holding a

DRANZCOG or DRANZCOG Advanced qualification.
If you work in a rural or remote area you can
participate in SOLS by requesting locum cover.
To receive a locum SOLS applicants must meet the following
requirements:
Practise in rural or regional areas of Australia currently defined
as RRMA 3-7.
Specialist applicants must be Fellows of RANZCOG, overseas
trained specialists practising obstetrics or Area of Need specialist
obstetricians.
GP obstetrician applicants are not required to hold a RANZCOG
qualification, but must be credentialed to practise obstetrics in
Australia.
For more information contact SOLS:
Katie Juno
(t) +61 3 9412 2912
(e) kjuno@ranzcog.edu.au
(w) www.ranzcog.edu.au/sols/index.shtml
The College
Tribute to William Refshauge

Major-General Sir William Dudley Duncan Refshauge
1913 2009
Soldier, Public Health Administrator and Ethicist

Born in Melbourne on 3 April 1913, Sir William was educated
at Scotch College and studied medicine at the University of
Melbourne, graduating MBBS in 1938. He was a Resident Medical
Officer at the Alfred Hospital in 1939.
At the outbreak of war in 1939, he joined the Australian Imperial
Force (AIF) as a medical officer with rank of Captain in the 2nd
Field Ambulance. He served in the Middle East, Bardia, Tobruk,
Crete, New Guinea, South West Pacific and Borneo. In 1944,
he was awarded the Order of the British Empire (OBE) and was
mentioned in dispatches four times.
Returning from the Middle East, Sir William married Helen Allwright.
On discharge from the army he worked at the Royal Womens
Hospital, Melbourne, obtaining his MRCOG in 1947. In his
memoirs, Sir William made special mention of Dr Morton Lemmon,
a consultant who was interested in training standards, especially in
relation to the first RCOG examination held in Australia in 1947.
After a year as the O and G in a group practice, he was appointed
first Medical Superintendent/Administrator at the Womens from
1948-1951. He was particularly interested in treatment and
transport of premature babies and helped design the first portable
humidicrib. He worked with Dr Kate Campbell researching
exchange transfusion and oxygen levels in acquired retrolental
fibroplasias. He oversaw the return of consultants from the war,
introduced a system of peer review for honoraries based on Sir
Herbert Schlinks Sydney model and initiated the first use of closed
circuit television in medical education in the Southern Hemisphere.
Sir William was active in ex-service affairs and Legacy. He was a Life
Member of the Returned and Services League (RSL) and a National
Trustee until his death. He was awarded the RSLs Anzac Peace Prize
for his contribution to world health and peace, and also the RSLs
highest award, the Meritorious Service Medal. Following retirement,
he was involved with the World Medical Association and WHO.
He was passionate about medical ethics and was involved in the
rewriting of the Helsinki Declaration of Ethics.
Sir William held positions at the Walter and Eliza Hall Institute of
Medical Research and various organisations related to alcohol and
drug abuse. He was also Patron of Sports Medicine Australia, the
Medical Association for Prevention of War (Australia) and various
charitable organisations.
Sir William died on 27 May 2009, aged 96. He is survived by three
sons, a daughter and their families.
Sir William Refshauge was a man of great vision who inspired
and motivated all who came in contact with him. He achieved
extraordinary standing in his various communities. He was a great
Australian who gave a lifetime of service to his country, to his fellow
Australians and to humanity.
Dr Keith Barnes AM
FRANZCOG
Australian Captial Territory (ACT)
With the onset of the Korean War, Sir William rejoined the Army
as Deputy Director-General of Army Medical Services, later
Director-General with rank of Major-General. He was awarded
a Companion of the British Empire (CBE) in 1959 for his army
services and the Efficiency Decoration in 1965. In 1966, he
was created Knight Bachelor. Subsequent honours included the
Companion of the Order of Australia (AC) and an Honorary
Doctorate of Medicine from the University of Sydney.
Sir William was Director-General of the Commonwealth
Department of Health from 1960 to 1973, during which time
he made many major contributions to public health, including
doctors fees, dental health, treatment of alcohol and drug abuse
and the introduction of dung beetles into Australia to reduce the
fly population. Other areas of involvement were the investigation
of thalidomide, legislation on contraceptive advertising, universal
vaccinations, aboriginal health and quarantine. He initiated antismoking campaigns and extended the fluoridation of water. He
was a Foundation Fellow of the RACOG in 1978.
In 1983, Sir William was involved with the Menzies Centre for
Population Health Research which, focused on Sudden Infant
Death Syndrome (SIDS). His interest in sports medicine was
recognised by the annual Sir William Refshauge Oration at Sports
Medicine Australia conferences.
The College
Obituaries
Dr Hugo Ulrich Herbert von Alpen
Professor James Boyer Brown AM
Hugo von Alpen was born on 5 February 1927 in Toowoomba,

Queensland. He attended Maryborough High School and The
Southport School where he was Dux and a champion athlete. He
spent 1945 at Toowoomba Grammar School prior to entering
Kings College, where he commenced studying medicine at the
University of Queensland in 1946.
The scientific and medical community mourns the loss of our

esteemed colleague and good friend, Emeritus Professor James
Boyer Brown AM, who passed away on 31 October 2009, aged 90.
1927 2009
Hugo graduated in medicine in 1951. In 1952, he married Shirley

Compton and they went to Innisfail Hospital where he was a
resident. In 1954, he began general practice as a solo practitioner
at Springsure, central west Queensland. It was then Hugo decided
on a career in O and G.
1919 2009
Born on 7 October 1919 in New Zealand and educated at

Auckland University College, James was manpowered to the
laboratories at Auckland Hospital early in the Second World War.
He rationalised sterilisation procedures at the hospital, qualified
in bacteriology, haematology and histology and built up the
biochemistry laboratory from some simple backroom tests to the
type of facility that exists today. He also set up the blood bank,
the monitoring of blood electrolytes and the production of sterile
solutions for peritoneal lavage (the precursor of renal dialysis).
Hugo began specialty training in 1957 at the Royal Hospital for

Women, Paddington, and later at Launceston General Hospital and
Queen Victoria Hospital, Adelaide. In 1960, he travelled to England
to further his training and worked at Walton Hospital, Liverpool,
gaining his MRCOG in 1962. Returning to Adelaide, Hugo was
appointed resident obstetrician at Queen Elizabeth Hospital,
Woodville, South Australia.
During the war, when chemicals were in short supply, James

developed methods for synthesising or regenerating them, using
techniques that often required innovative use of materials available.
His ability to innovate was a skill that he used to great advantage
throughout his life.
Hugo (Vonnie) was a talented obstetrician and gynaecologist who

excelled at teaching. He passed on his many skills to medical
students, particularly in the use of forceps. He entered private
practice in 1965, with honorary appointments at Queen Elizabeth
Hospital and Royal Adelaide Hospital and began a lifetime of
service dedicated to the women of the western suburbs.
After the war in 1947, James developed an interest in

endocrinology and reproduction and started a small animal
breeding surgery. He set up bioassays for urinary gonadotrophins
and estrogen (the female hormone) and concluded that the most
important requirement in human reproduction was the development
of a highly accurate method for timing ovulation in women. He
received a National Research Scholarship to work in Edinburgh
under Professor Guy Marrian, one of the discoverers of estrogen.
Hugo supported the GP obstetricians who worked at the small

community hospitals including Henley and Grange, Thebarton,
Hindmarsh and Le Fevre hospitals. He mentored the young O and
Gs, giving freely of his time to provide advice and encouragement.
In 1971, Hugo spent time in the United States and Mexico training
in laparoscopy and reproductive medicine. On his return, he
became one of a pioneer group of laparoscopic surgeons in
Adelaide. He became a Foundation Fellow of the RACOG in 1979
and was elevated to Fellowship of the RCOG in 1982. Hugo and
Shirley were involved in planning and fundraising to develop the
Western Community Hospital, which along with Calvary Hospital
and St Andrews Hospital, formed the base of his extensive private
practice.
Hugo retired from practice in 1994. He passed away on 3 April
2009 and is survived by his wife Shirley, two sons, a daughter and
seven grandchildren. He will be remembered as a big man with a
big heart who was respected by his medical colleagues and nursing
staff alike.
A/Prof John Svigos

FRANZCOG
South Australia
70 O&G Magazine
Dr Basil Antonas
FRANZCOG
South Australia
His aim was to develop a chemical method for measuring estrogen

in urine and was given a position in the new clinical endocrinology
research unit in Edinburgh, later to be appointed its Assistant
Director. Notwithstanding Marrians attempts at dissuading him from
this project, James persisted and the essential problems were solved
within a few months, but a fully validated method was not published
until 1955. This published paper has been cited over 1000 times
and was awarded a full Citation Classic by the Institute for Scientific
Information.
Using this new method of measurement, James confirmed the
elegant patterns of estrogen production throughout the menstrual
cycle. This work led to a PhD and The Lancet requested the privilege
of publishing the results obtained. His method was the gold
standard for measuring these hormones for almost 20 years until
superseded by radioimmunoassays on blood. He also collaborated
with Arnold Klopper in developing a urinary preganediol assay in
non-pregnant women, which was awarded a half Citation Classic.
Possibly one of the greatest contributions made by James in his early
days in Edinburgh was the use of human gonadotrophin for the
induction of ovulation. Working with colleagues, they purified these
hormones and later developed the International Standard Reference
Preparation, facilitating their widespread usage. The Edinburgh
unit was the second in the world to use human gonadotrophins
for ovulation induction in humans, but James, later working in
Melbourne, would properly rationalise their usage.
The College
In 1962, he was appointed First Assistant in the department of
O and G at the University of Melbourne under Professor Lance
Townsend. This was despite many attractive offers from the United
States, including one from Dr Gregory Pincus, the originator of the
oral contraceptive pill. It was here that he showed his true genius
and, in conjunction with his colleagues at the Royal Womens
Hospital, he revolutionised the use of gonadotrophins for the
safe induction of ovulation. He refined the method for measuring
urinary estrogen, making it effectively a routine test which could
be performed in a few hours, thereby enabling these drugs to be
used in a safe manner and all but eliminating the risk of high order
multiple pregnancies, which had been a feature of this treatment up
until that time. This was the first time that this approach had been
used and led to James developing the threshold theory of ovarian
follicle stimulation, which stands unchallenged today in reproductive
medicine.
James further modified his rapid assay method to enable urinary
estrogen to be measured during pregnancy, which was used to
great effect by obstetricians as a test of placental function and fetal
well-being during pregnancy.
Are you interested in

donating items to the
Historical Collections?
We welcome enquires regarding donations.
If you have any items that you believe might be of value to

the Historical Collections and you would be interested in
donating them, please see the instructions below:
Compile a list of items with a brief description. For
books, include author, title, publisher, place and date.
For archival and personal papers, include details.
For museum items, include a brief description and the
During a sabbatical year in 1970, James gained a DSc from

the University of Edinburgh and delivered 63 lectures and
demonstrations in Europe and the United States.
Notwithstanding the advent of radioimmunoassay, the laboratory
continued to be world renowned for its urinary assays and attracted
large contracts, principally from Harvard University for studying risk
factors in breast cancer and from Family Health International for
studying the return of fertility during breastfeeding. The work with
Harvard won the Prix Antoine Lacassagne from Paris as the most
important contribution to the study of breast cancer for that year.
In 1971, James was given a Personal Chair in the department of
O and G at the University of Melbourne and was a member of the
IVF team led by Professor Carl Wood. His work and understanding
of ovarian function has been linked to the development of the
early techniques for egg pick-up in IVF and were used in the first
successful IVF pregnancy in Britain.
James retired in 1985 and was accorded the title of Emeritus
Professor. Nonetheless, he continued to work in the field. In 1962,
he had established a close working and personal relationship
with John and Lynn Billings, who developed the concept of fertility
recognition through the changes in cervical mucus secretion,
forming the basis of natural family planning. He validated their
findings and continued to work closely with them, especially in his
latter years when he developed the home ovarian monitor
a kit that can be easily used at home, even by those without any
laboratory training, to check their hormonal status. This was a
quantum leap from his early methods. Up to the time of his death,
James continued to work on various scientific projects and was
involved with the Special Program of Research, Development and
Research Training in Human Reproduction (WHO).
James Brown is survived by his wife Wendy and their four children.
Dr Adrian Thomas
FRANZCOG
Victoria
history of how you acquired it and attach a photograph.

Email or post the list to one of the Historical Collections
staff at the College.
Contact the staff by telephone if you wish to discuss
any items.
We look forward to hearing from you and would be

delighted to consider any items you may wish to donate.
Librarian: Di Horrigan
ph: +61 3 9412 2927
Tuesday 9am-5pm
email: dhorrigan@ranzcog.edu.au
Museum Curator: Grinne Murphy

ph: +61 3 9412 2927
Archivist: Ros Winspear

ph: +61 3 9412 2934
Monday 9am-5pm
email: gmurphy@ranzcog.edu.au
Mon, Wed, Thu 9am-5pm
email: rwinspear@ranzcog.edu.au
Notice of Deceased Fellows

The College was saddened to learn of the death of the following:
Dr Beryl Collier, New South Wales, on 1 August 2009.
Dr Noel Docker, New South Wales, on 4 August 2009.
Dr Helen Mackenzie, Victoria, on 18 September 2009.
RANZCOG
Research Foundation
DID YOU KNOW?

RANZCOG RESEARCH FOUNDATION FACT SHEET
The RANZCOG Research Foundation encourages and supports research in the fields of
obstetrics, gynaecology, womens health and reproductive sciences and specifically provides
support for scientific and clinical research through research fellowships, scholarships and travel
grants. The Foundation especially supports the development of the research careers of trainees
and early career Fellows of the Royal Australian and New Zealand College of Obstetricians and
Gynaecologists (RANZCOG).
The RANZCOG Research Foundation works closely with the RANZCOG Executive, Council and
Council Committees to further the needs for research and research training in the broad fields
of obstetrics, gynaecology, womens health and reproductive sciences.
For almost 50 years, the RANZCOG Research Foundation has been supporting research training
for promising young Australian Fellows and scientists who undertake high quality research and
research training at an early stage of their careers.
The RANZCOG Research Foundation disburses approximately $120,000 annually towards basic
and advanced research training in obstetrics, gynaecology and in womens health.
Scholars have a strong record of subsequent achievement in research and in academic careers
in Australia and overseas.
The RANZCOG Research Foundation has sponsored young Fellows and scientists in undertaking
innovative research in a number of exciting projects in recent years. For example, stem cells
from human endometrium.
The RANZCOG Research Foundation recently made the decision to enhance its support for
RANZCOG trainees in their research endeavours during the FRANZCOG training program.
Helping to drive research excellence in womens health

RANZCOG Research Foundation (ABN 23 004 303 744)
College House, 254-260 Albert Street, East Melbourne, Victoria 3002, Australia
t: +61 3 9417 1699 f: +61 3 9419 0672 e: researchfoundation@ranzcog.edu.au w: www.ranzcog.edu.au/research
The College
RANZCOG Research
Foundation
RANZ
Resea
Scholarships, Fellowships and Grants in 2010

Professor John Newnham
Chair, Scholarship Selection Committee

The Scholarship Selection Committee of the RANZCOG Research Foundation met on 4 September 2009 to
consider the awarding of Scholarships, Fellowships and Grants offered for 2010. This includes the awarding of
the inaugural Mary Elizabeth Courier Research Scholarship, a three-year scholarship dedicated to research into
gynaecological cancer. The recepients and their research are listed below.
Arthur Wilson Memorial Scholarship, 2010-2011

Awardee:
Mr Terence Chua
Project:
Phase III Randomised Clinical Trial of Cytoreductive Surgery and Hyperthermic Intraperitoneal
Chemotherapy in Ovarian Cancer
Institution:
St George Hospital Sydney; Department of Surgery and Department of Gynaecology Oncology
Supervisors:
Professor David Lawson Morris and Dr Gregory Robertson
Fotheringham Research Scholarship, 2010-2011

Awardee:
Dr Lisa Hui
Project:
Functional Genomic Analysis of Amniotic Fluid mRNA in Monochorionic Twins with Twin-to-Twin
Transfusion Syndrome
Institution:
Tufts Medical Center, Tufts University, Boston Massachusetts, USA;

Department of Obstetrics and Gynaecology; Department of Paediatrics
Supervisor:
Dr Diana Bianchi
Luke Proposch Perinatal Research Scholarship, 2010

Awardee:
Dr Veronica Stevens
Project:
Role for the b-Isoform of the Thromboxane Receptor in Pre-eclampsia
Institution:
Kolling Institute for Medical Research; Department of Perinatal Medicine
Supervisor:
Dr Anthony Ashton
Mary Elizabeth Courier Research Scholarship, 2010-2012

Awardee:
Dr Viola Heinzelmann-Schwarz
Project:
Evaluation of an Anti-glycan Antibody Panel as New Diagnostic Signature in Serous Ovarian

Cancer Patients
Institution:
Royal Hospital for Women; Gynaecological Cancer Centre

Lowy Cancer Research Institute; Translational Ovarian Cancer Group
Supervisor:
Professor Neville Hacker

The College
Taylor-Hammond Research Scholarship, 2010

Awardee:
Dr Christos Georgiou
Project:
Variations in the Molecular Structure of the Oxytocin Receptor and Oxytocinase
Institution:
University of Wollongong/Wollongong Hospital; Department of Obstetrics and Gynaecology
Supervisor:
Professor Wilf Yeo
Brown Craig Travel Fellowship, 2010

Awardee:
Dr Renee Wong
Travel:
To complete Year 6 training as a maternal fetal medicine fellow. Gain experience in high-risk
obstetrics. Participate in a research project involving obstetric ultrasound: Placental Ultrasound
in Low-risk Pregnancies
Institution:
Mt Sinai Hospital, Toronto, Canada; Department of Obstetrics and Gynaecology
Supervisor:
Dr John Kingdom
Arthur Wilson Memorial Scholarship, 2009-2010

Awardee:
Dr Tuuhevaha Kaituu-Lino
Project:
The Contribution of Endometrial Stem/Progenitor Cells to Endometrial Restoration After Menses
Institution:
Monash University; Department of Obstetrics and Gynaecology

Monash Institute of Medical Research; Centre for Womens Health Research,
Supervisor:
Dr Caroline Gargett
Ella Macknight Memorial Scholarship, 2009-2010

Awardee:
Dr Toni Welsh
Project:
The Role of Progesterone and Prostaglandins in Controlling the Timing of Labour
Institution:
University of Newcastle; Mothers and Babies Research Centre
Supervisor:
Associate Professor Tamas Zakar
Glyn White Research Fellowship, 2009-2010

Awardee:
Dr Ryan Hodges
Project:
Prevention of Preterm Lung Disease by Human Amnion Cells
Institution:
Monash University; Department of Obstetrics and Gynaecology
Supervisor:
Professor Euan Wallace and Dr Hayley Dickinson
Do you have a RACOG Fellows gown

that you no longer need?
If so, the Image and Regalia Working Party would like to hear from you as they are keen to obtain RACOG Fellows gowns that are no
longer used by their owners. The aim is to build up the existing collection of gowns at the College. We plan to have the gowns available
for the use of members of Council, new Fellows being presented with their Fellowship and for hire by Fellows for special occasions
(a fee is charged for the hire of the gowns to cover postage and handling).
The gowns can be upgraded to a RANZCOG gown with the addition of silver braid.
The collection of gowns is kept in a special storage area and maintained in excellent condition.
The gowns are used by the Council members at every College function including Council meetings.
Any enquiries please contact:
Ros Winspear
Coordinator, Image & Regalia Working Party
+61 3 9412 2934 fax: +61 3 9419 0672 email: rwinspear@ranzcog.edu.au
Magazine
74 O&Gph:
Membership of the RANZCOG Research Foundation is open to all

members of the Royal Australian and New Zealand College of
Obstetricians and Gynaecologists (RANZCOG) and to all others with an
interest in the aims and objectives of the Foundation.
RANZCOG
Research Foundation
Medical research in Australia and New Zealand is internationally

recognised for its excellence. By joining the RANZCOG Research
Foundation, you are directly contributing to this research and in particular,
to the future of womens health.
The Foundation also welcomes donations. Both membership fees and

donations are tax deductible.
Application for Membership and
Donation to the RANZCOG Research Foundation

Name:
Postal Address:
Annual Subscription: 1 July 2009 - 30 June 2010

Fellows in Australia
$AUD110.00
Fellows overseas
$AUD100.00
Others (non-Fellows) in Australia
$AUD55.00
Others (non-Fellows) overseas
$AUD50.00
Includes 10% GST
Includes 10% GST
Donation to the RANZCOG Research Foundation

$50
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Other
The Foundation is proud to accept and acknowledge donations.

I give the RANZCOG Research Foundation permission to publish my
name as a donor to the Foundation in any College publications.
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No
Total amount payable: $AUD

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The College
Staff News
New appointment
Katie Juno
Katie joined RANZCOG in May 2009 as the

Specialist Obstetrician Locum Scheme (SOLS)
Coordinator. She has a background in both
accountancy and design. Prior to joining
RANZCOG, Katie worked as a freelance textile
designer for a UK-based company.
Departures
Holly Coppen
RANZCOG
Womens
Health
Award
Emily Gregory-Roberts, a student from Sydney Medical School
(University of Sydney), received the RANZCOG Womens Health
Award for 2008. Congratulations, Emily.
Holly has resigned from her role as Support Scheme for Rural
Specialist (SSRS) Projects Coordinator and Fetal Surveillance
Education Program (FSEP) Administrator. She is planning to live
and work abroad in 2010. We wish Holly all the best for her travels.
Sonya Andrew
Sonya has resigned from her role as Overseas Trained Specialist

Coordinator. She is returning to New Zealand and we wish her all
the best for the future.
Hannah Tosolini
Hannah has resigned from her role as Overseas Trained Specialist

Administration Officer. We wish Hannah all the best for the future.
Susan Westcott
Susan has resigned from her role as Subspecialties and Continuing

Professional Development Administration Officer. We wish Susan
well for the future.

subject indexes.
Emily Gregory-Roberts (left) being presented her

award by Dr Kirsten Black, FRANZCOG (right).
Medical pamphlets


PO Box 24
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ph: +61 3 9888 6262
fax: +61 3 9888 6465

indexes useful!

76 O&G Magazine
RANZCOG
GIFTSHOP
SALE!!
UP TO 50% OFF ALL ITEMS FOR A LIMITED TIME ONLY. SALE ENDS 31/01/10
ALL PRICES ARE GIVEN IN AUSTRALIAN DOLLARS AND INCLUDE GST.
Medical responses to adults who

have experienced sexual assault: an
interactive educational module for
doctors.
Umbrellasnavy blue with College

crest in gold:
Small folding umbrella with
wooden handle. Was $24.20
NOW $12.50
L:arge golf umbrella, clear
lacquered wood handle.
Was $33 NOW $16.50
Long umbrella, clear lacquered
wood crook handle. Was $27.50
NOW $14.00
Collaboratively produced by a
working party of experts in the field
and representatives from eight
medical colleges, as well as the
contributions of numerous specialist
advisors, this module is a high
quality educational tool
incorporating assessment tasks,
activities and readings.
Was $50 NOW $20
Rugby topsnavy blue with embroidered College crest

(65% polyester / 35% cotton).
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Small folding umbrellanavy, gold crest, wood handle$ 12.50
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Golf ballsBridgestone B330 Tour $15.00 set of 3
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Actual garment size as follows:

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outside of Australia or New Zealand, we recommend
contacting College House to discuss orders..
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when payment has been received.
Nuchal Translucency
Online Learning Program
Purpose
The Nuchal Translucency Online Learning Program (NTOLP) is designed to replace the theoretical course that is
conducted for operators who wish to become credentialed to perform Nuchal Translucency scans.
Content
The NTOLP covers eight topics:
1. Principles of screening
2. Practicalities of NT measurement
3. NT and chromosome abnormality
4. Biochemical screening
5. 12-week anomaly scan
6. Screening test results and informed choice
7. Screening and multiple pregnancy
8. Increased NT and normal chromosomes
Features
This site uses many elements to engage and interest the learner. Some examples are:
Interactivity mouse over, prediction tasks and multiple choice questions
Customised images graphs, detailed diagrams, flash animations and ultrasound scans
Illustrations and text
Discussion Forums
The course is now live and costs A$165.00 incl. GST per individual. Please visit www.nuchaltrans.edu.au/ for further
details or to enrol. This program is co-located with The Royal Australian and New Zealand College of Obstetricians and
Gynaecologists (RANZCOG) and development has been funded by the Australian Department of Health and Ageing.
Are you planning to survey members of RANZCOG?

Did you know that your survey must be submitted to the RANZCOG CPD Committee for approval?
This process was introduced in June 2000 to regulate the content and number of surveys being sent to the
RANZCOG membership.
Documentation required by RANZCOG:
RANZCOG criteria document detailing your survey
Final survey
Letter to be sent to participants with the survey
Letter to CPD Chair from survey author detailing the purpose of the survey and identifying the class (eg Fellows/
Trainees/Diplomates) of College members that you wish to survey and the location (eg Australia, New Zealand or State).
RANZCOG requires that a disclaimer (as detailed in the approval letter) be appended to all approved surveys and that the
applicant provide feedback of results and copies of any subsequent publications to the CPD Committee.
For further information and the survey criteria document please contact:
Val Spark
(t) +61 3 9412 2921
(f) +61 3 9419 7817
(e) vspark@ranzcog.edu.au
Author Index: Volume 7 to Volume 11

Author Index
Volumes 711, 2005-2009
Volume numbers will appear first in index entries, issue numbers
in brackets afterwards and page numbers following: for example,
10(1):18 = Vol 10, No 1, page 18.
Articles A, In and The are ignored in filing entries.
Editorials, obituaries, series titles and other statements of
responsibility are noted in closed brackets [ ].
Abbott, Jason, Endometrial ablation 9(3): 42-45

Abbott, Jason, Endometriosis surgeons 2020, given a stay of
execution 7(1): 22-23
Abraham, Suzanne, Are we adequately training specialists in
womens mental health 7(4): 53-55
Adair, Steve See Ranka, Poomima
Adair, Steven R, Collapse in obstetrics: acute management of the
collapsed or immediately post-partum patient 8(2): 33-35
Ah Ching, John, Extreme obstetrics on a Pacific Island [edited by
Alec Ekeroma] 8(2): 11
Airey, Yvonne and Mellor, Anthony, Dr George P Mellor [obituary]
9(4): 82
Allenby, Keith, Labour and delivery in obese women 10(4): 14-16
Allenby, Keith, New Zealand training: has it reached a turning
point? 7(2): 17
Anderson, Iain, How GP obstetricians in remote areas interact with
academics in larger centres 10(1): 22, 24
Anna, Vibeke See Huxley, Rachel
[Anonymous], Antenatal classes: an Australian patients perspective
11(4): 24
[Anonymous], Antenatal classes: a New Zealand patients
perspective 11(4): 24
[Anonymous], Breast reduction surgery: a patients perspective 9(3):
33
[Anonymous], A Hiccup along the way: a personal experience of
surviving breast cancer 9(3): 36-37
Antonas, Basil See Svigos, John
Arnold, Joanna [Q&A] 10(1): 59
Arnold, Joanna, Working in the wild North West 9(2): 77-79
Atkinson, Elinor, [Q&A] 8(2): 71
Ayton, Jeff, Womens health in Antarctica: Antarctic medicine in
Australias Antarctic program 8(2): 16-18
Baber, Rod, HRT and the heart 10(3): 48-49

Baber, Rod, Using HRT in older women (9) 1: 20-21
Baird, Tony, Obstetrics: art or science? 11(4): 12-13
Baird, Tony, Walter Stewart James Tongue [obituary] 8(4): 68
Baker, Gordon See Stewart, Tanya
Barnes, Keith, Major-General Sir William Dudley Duncan Refshauge
[obituary] 11(4): 69
Barry, Chris, FLP: anatomy & embryology 7(2): 22
Barry, Christopher See Kaladelphos, George
Bass, Eileen, Management of heart disease in pregnancy 10(3):
21-24
Bayly, Christine, Informing the abortion debate 7(1): 50-51
Bell, Robin, FLP: epidemiology & statistics 7(2): 27
Bencini, Franco, Geoffrey Clare [obituary] 7(3): 70
Benn, Cheryl, A midwifes perspective on homebirth in New Zealand
11(4): 34-35, 37
Bennett, Michael, The incompetent cervix 8(4): 16-17
Bennett, Michael and Deans, Rebecca, Review of current
management of congenital abnormalities of the femal reproductive
tract 10(1): 54-55, 57
80 O&G Magazine
Bethune, Michael, Soft markers detectable at the mid-trimester

ultrasound 11(2): 22-24
Biggs, Janice See Sullivan, Elizabeth
Biggs, John, Dr Innayat Khan [obituary] 10(3): 85
Biro, Mary Ann, Who will be delivering babies and where will they
be born in 20 years time? 8(1):15
Birt, Stewart, Congratulations! Its a 8(3): 18-19
Bishop, Geoffrey J, Barry Lee Griffiths Kneale [obituary] 7(1): 66-67
Bishop, Geoffrey J, Cyrus Arvon Jones [obituary] 10(3): 73
Bishop, Geoffrey, James Gavin Amess Troup [obituary] 8(1): 34
Black, Jules, Sex and the gynaecologist II: psychosexual O and G
8(3): 27
Blackham, Ruth, In memory of Dr Camille Michener [obituary]
11(3): 63
Bloomfield, Penny [et al], The new 2005 NHMRC pap smear
guidelines are safe for Australian women and based on peer
reviewed evidence [Points of View] 8(1): 47
Bloomfield, Penny [et al], The new NH&MRC guidelines for
management of abnormal pap smears in asymptomatic Australian
women 7(3): 25-27
Bohlsen, Terence, Dr Vijayaratnam Balchandran [obituary] 10(3): 74
Borosh, Cherish See Quinn, Frank
Bowden, Francis J, Its there if you look: chlamydia in obstetric and
gynaecological practice 7(3):16, 18
Bowditch, John, Tamoxifen on the endometrial [Points of View] 7(1):
15, 80
Bowman, Mark, REI subspeciality training programs and male
infertility [Points of View]7(4):10
Brabin, Penny, Bereavement after perinatal loss: Who cares? SANDS
does 7(4): 22
Bradford, Jenny, The approach to the obese patient: a personal
view 10(4): 17-18
Brand, Alison, The myth of screening for epithelial ovarian cancer:
can we finally lay it to rest? 11(4): 43-45
Breeze Carol, Climate change and trainees 9(2): 25, 74
Breeze, Carol and de Costa, Caroline, Indigenous women &
cervical cancer 7(3): 28-29
Briggs, Greg, Interventional radiology: a viable alternative to
gynaecological surgery? 7(1): 30-32
Broadley, Simon, [Perspectives on medical students delivering
babies] 10(1): 33
Brodribb, James, Deaths following gynaecological surgery for
benign conditions 11(1): 24-25
Brodribb, James, The future of obstetric practice: group practice
8(1): 11
Brown, Douglas, Bryan Nelson Foy [obituary] 8(2): 69
Browning, David R, Suggestions for interdependence between
specialists and subspecialties [Points of View] 7(1): 12
Brunello, Lawrie, My! How O and G has changed! 8(4): 9, 34
Bryan, Nicole See Crozier, Karen
Bryant, Christian and Larsen, Stephen, Anaemia in pregnancy 11(3):
17-18
Buckland, Emma and Quinlivan, Julie [an interview with], Surveying
obstetricians awareness of herpes viruses in pregnancy 7(2): 31-32
Buist, Anne, Guidelines for the use of SSRIs in pregnant women
7(4): 18-20
Buist, Anne, PND: Postnatal or perinatal? depression 7(4): 13-14
Bull, Ange, Midwives teaching medical students at Royal Darwin
Hospital 10(1): 36-38
Bushati, Tony See OSullivan, Brendan
Calcutt, Cait, Abortion services in Australia 9(4): 27-28

Campbell, Janine, FLP: haematology & pathology 7(2): 23
Campbell, John McNeil, Dr David Victor Moni [obituary]10 (3):
73-74

Campion, Michael, Reflections on: Banda Aceh 7(3): 55-57
Carey-Smith, Ross Gordon [obituary] 10 (1): 94
Carlsen, Victoria, The changing climate for New Zealand Trainees
9(2): 22
Carlton, Mark, Charles Emmanuel Ponnuthurai, [obituary] 9(3): 91
Carmody, Frank, Nuchal translucency screening 9(4): 38-41
Case, Deena, Postpartum haemorrhage in a very remote hospital
11(3): 36-37
Casper, Gabrielle, Diana Jakubowicz [obituary] 9(3): 91
Chinnock, Marian See Schibeci, John & Robson, Steve
Chinnock, Marian, Fear and loathing in Launceston: tales from a
registrar research project 10(1): 25
Christie, Damian, Assessing the pros & cons of the training model
[an interview with Marcus Miller] 7(2): 15-16
Christie, Damian, [an interview with Birgit Strong] Gynaecological
surgery: an international experience 7(1): 36, 46-47
Cho, Carolyn, Managing mastalgia: its not as painful as you think
9(3): 26-27
Clark, Erin, Peripartum cardiomyopathy 10(3): 25-27
Clark, Katherine, Providing care at the very end of life 11(1): 43-44
Clark, Kenneth, Peter Cameron Stichbury [obituary] 7(2): 75
Clark Kenneth, Change in obstetrics: can clinicians have influence?
9 (2): 15-16
Clements, Sarah D, A Trainees personal experience of the Flexible
Learning Program 8(1): 69-70
Cody, Terence and Dodkin, Marilyn, Delmont Puflett [obituary]
10(1): 94
Cohen, Jonathan, Overseas travel and pregnancy: pre-travel
guidelines and advice 8(2): 28-30
Collins, Des, Brendan Keane [obituary] 8(3): 85-86
Cooper, Steve and Parmar, Ramesh, Fetal cardiac anomalies 10(3):
30-31
Cordina, Rachael and Patel, Anushka, Women and coronary artery
disease 10(3): 15-17
Court, Denys, Informed consent in labour: New Zealand perspective
11(4): 60-61
Crooke, David, Managing labour pain, 8(4): 23-25
Crowe, Peter, Philip Arnold Deck [obituary] 11(3): 90
Crowley, John See Parry, Gordon
Crozier, Karen and Bryan, Nicola, Surgical training: the perspectives
of two trainees 7(1): 48
Cvach, Kristina, Fiji living 9(3): 58-59
Daniels, Brett and Robson, Steve, Facing death [editorial] 11(1): 10

Daniels, Brett,[Perspectives, should medical students deliver babies?]
10(1): 33
Day, Arthur and Best, Jack, Peter Sydney Allen [obituary] 10(1): 95
Deans, Rebecca See Bennett, Michael
de Costa, Caroline See Breeze, Carol
de Costa, Caroline See Robson, Steve
de Costa, Caroline, Abortion [editorial], 9(4): 26
de Costa, Caroline, A Bloody business: a short history of placenta
praevia 8(3): 36-38
de Costa, Caroline, Brazilians, pubic hair sculpting and
more8(3): 20-21
de Costa, Caroline, Childbed fever 11(1): 45-46
de Costa, Caroline and Howat, Paul, The difficult caesarean
section 8(1): 54-57
de Costa, Caroline, Holding a mirror to life: Moliere, William
Harvey and the circulation of the blood 11(3): 42-44
de Costa, Caroline [Q&A] 7(4): 38 (check with Rachel/Ros De
Costa or de Costa)
de Costa, Caroline and Robson, Steve, Preaching to the converted
[editorial] 10(2): 8
de Costa, Caroline [prepared by] Preventing eclampsia: art or
science? 11(4): 21
deCosta, Caroline, Quickening [editorial] 11(2): 11
de Costa, Caroline, [including a patients story] Rural womens

access to termination of pregnancy: the view from Far North
Queensland 7(1): 58-60
de Costa, Caroline, Should medical students deliver babies? 10(1):
30-35
de Costa, Caroline and Robson, Steve, Paparazzi and the
obstetrician 10(2): 62-63, 65
de Costa, Caroline and Robson, Steve, Town and gown [editorial]
10(1): 9
de Crespigny, Lachlan, Australian abortion laws: do they pose a
health hazard? 7(1): 52-54
de Crespigny, Lachlan, Ultrasound for entertainment, 8(4): 54-55
de Crespigny, Lachlan, Ultrasound for entertainment: double
standards or simple medical self interest? 11(2): 38-40
De Jong, Reflections on: Banda Aceh 7(3): 53-54
Dekker, Gus, Venous thrombo-embolism in pregnancy 8(4): 32-34
Dennerstein, Graeme, Response to the edition on obesity [letters to
the editor] 11(1): 52
Dennerstein, Graeme, Vulval pain 8(3): 54-55
Dennis, Amanda, [Q&A] 10(4): 43-44
De Paoli, Antonio, Counselling parents expecting an extremely
preterm baby 11(2): 33-34
Devenish, Celia, Elder friendly clinics 9(1): 11-12
Devenish, Celia, Preconception care 9(4): 21-22
Devenish, Celia, Standards of antenatal care 11(4): 22-23
Devine, Bronwyn and Parekh, Vanita, Acute pelvic inflammatory
disease 7(3): 20-21
Dewhurst, Fleur, Informed consent in labour 11(4): 59
Dickinson, Jan, High order multiple gestations 8(2): 36-37, 56
Dickinson, Jan, Late termination of pregnancy: practical realities
9(4): 33-35
Dodkin, Marilyn See Cody, Terence
Douvos, George, The Flexible learning program FLP: an overview
7(2): 21
Drielsma, Robert, Breast aesthetic surgery: a plastic surgeons
perspective 9(3):31-32
Duke, Janet, Anglicanism and womens health 10(2): 9-10
Dunlop, Scott, Down syndrome: an approach to children and their
families 11(2): 17-19
Duursma, Louise See Hogan, Monica
Eames, Mai See Jayasinghe, Yasmin

Eastman, Creswell, Iodine supplementation: the benefits for
pregnant and lactating women in Australia and New Zealand 7(1):
65-66
Eddy, Alison, Midwifery interventions for the promotion of
physiological birth 8(4): 14-15
Eden, John, Modern management of premenstrual syndrome (PMS)
7(4): 26-28
Eden, John, [Q&A] 10 (3): 52-53
Eden, John, Tibolone for postmenopausal women 9(1): 13-14
Eizenberg, David [Q&A] 9(2): 54-55
Ekeroma, Alec See Ah Ching, John
Ekeroma, Alec [an interview with] FLP: cultural & womens health
issues 7(2): 29
Ekeroma, Alec, Management of chickenpox (varicella) in pregnancy
7(3): 17-18
Ekeroma, Alec, The obesity epidemic: a huge challenge to O and
G 8(2): 10
Elliott, Murray, Lionel Sapsford [obituary] 9(4): 82-83
Ellwood, David, Celebrating a quarter century of leadership in
perinatal medicine 10(1): 26, 28
Ellwood, David and Foletti, Simonette, ITP research project: the
focus on research in the RANZCOG curriculum 7(2): 30, 32
Englund, Michelle, How I learned to stop worrying and love my
research project 10(1): 25
Evans, Susan, A clinical approach to endometriosis and pain (9)1:
46-49

F
Farnsworth, Annabelle, Liquid based cytology: why not? 7(3): 32-33

Farrell, Louise, Geoffrey Douglas Roland Lilburn [obituary] 9(1): 77
Farrell, Louise, [Q&A] 11(3): 54
Farrell, Rhonda and Hammond, Ian, Preventing gynaecological
cancer in high-risk women 9(3):28-30
Farrell, Rhonda [Q&A] 10(2): 57
Faunce, Thomas, Religion, ethics, law and human rights in obstetric
research 10(2): 33-34
Ferguson, Russell, Ronald Milton Alder [obituary] 7(2): 73
Fiddes, Thomas, The older practitioner in obstetric and
gynaecological practice 7(2): 60-61
Fleming, Sue, [Q&A] 9(4): 50
Fleming, Sue, Sex chromosome aneuploidy diagnosis in the second
trimester 11(2): 25-27
Fleming, Sue [Further perspectives on should medical students
deliver babies?] 10(1): 38
Fleming, Sue, Shoulder dystocia 8(4): 48-49
Foletti, Simonette See Ellwood, David
Foote, Andrew, Informed financial consent, 9(4): 31
Foran, Terri, Vaginal discharges: a practical workshop 9(3): 64-68
Ford, Robert, Hartman, Keith and Stretch, Jonathan, Alan John
Ferrier [obituary] 11(2): 91
Ford, Robert, John Colin Pennington [obituary] 7(1): 67
Fraser, Sue, Breast screening for rural women 9(3): 18-19
Frazer, Malcolm, Rane, Ajay and Maher, Christopher, Case
for removing urogynaecology from the subspecialty canon is
retrogressive[Points of View] 7(1):11-12
Frucacz, Andrew, The mental health of women in detention centres
7(4): 56-58
Frumar, Tony, Frederick Hinde [obituary] 8(4): 67
Galbally, Megan See Snellen, Martien

Gartian, Gerard, David John (Jerry) Walters [obituary] 11(3): 91
Gee, Alison, See Jansen, Robert
Gibson, Gillian, Future of obstetric practice: group practice? 8(1):
10
Gilberg, Miranda and Spreer, Alicia, The impact of the death of a
practitioner on your practice 11(1): 50-51
Giles, Michelle, FLP: infectious diseases & microbiology 7(2): 24
Giles, Warwick, Fetal fibronectin use in the management of
threatened preterm labour 8(3): 39
Giorgio, Bruno See Mahmood and Scroggs
Goh, Judith and Krause, Hannah, Introducing emergency obstetric
care in the Amhara region, Ethiopia 10(2): 40-42
Goh, Judith, Management of urodynamic stress inconinence 8(1):
48-49
Graham Freddie, Fertility and IVF in older women 9(1): 18-19
Grant, Peter, Authors reply [Points of View] 7(1): 15, 80
Gray Elaine, Improving womens perinea health after birth 9(2):
30-31
Groom, Katie See McCowan, Lesley
Grover, Sonia, The obesity epidemic in children and adolescents
10(4): 24-25
Grover, Sonia and Lam, Pelyoong, Teenagers and consent issues
8(3): 80-81, 83
Guilliland, Karen, A Decade in review: midwives & the New
Zealand maternity system 7(3): 37-39
Guilliland, Karen, Obstetricians and midwives: a public and
political alliance 9(2): 23
Gyaneshwar, Rajat, Teaching in the Pacific 9(2): 64-65
Hacker, Neville F, A note of caution: laparoscopy and

gynaecological cancer 7(1): 26-27
Hakim, Claude, Robert Andrew Diamond [obituary] 8(4): 68-69
82 O&G Magazine
Halloway, Chris, Catholicism: its influence on my practice as an

obstetrician and gynaecologist 10(2): 14-15
Halloway, Chris, Travelling with Erinn: raising a child with Down
syndrome 11(2): 20-21
Hammond, Ian and Taylor, John, Improving obstetricians skills,
performance & knowledge: anatomy of complications 7(2): 62-63
Hammond, Ian See Farrell, Rhonda
Hankins, Gary See MacLennan & Speer
Hansson, Dale See Hogan, Monica (et al) double check with three
authors
Hartman, Kenneth See Ford and Stretch
Haslam, Alastair, Mercia Barnes [obituary] 11(1): 47
Haslam, Alastair, Maternal mortality in New Zealand 11(1): 23
Haslam, Alastair, Update on maternal deaths in New Zealand
11(2): 44
Haysom, Georgie, During infertility treatment, a specialist finds that
a man is HIV+ 8(1): 58-59
Hayward, Jenny, Early pregnancy loss 9 (2): 33-35
Healy, David See Scott, Jennifer
Healy, David, Research matters: the verb, not the noun 10(1): 2324
Henry, Amanda See Marsden, Donald
Hewson, Alan, Alan Coulthard [obituary] 7(2): 73-74
Hewson, Alan, Philip Rachow [obituary] 9(4): 84
Hewson, Alan, Robert Ian Davidson [obituary] 7(2): 74
Hewson, Alan, Robert Richardson [obituary] 9(4): 83
Hickling, Ralph, O and G: 2026 [Points of View] 8(2): 73
Hill, John Brian, Noel Clarkson Holmes [obituary] 10(3): 74-75
Hirst, Janes, Babies and more babies: O and G in Ho Chi Minh
City, Vietnam 10(1): 66-67
Ho, Tim See OSullivan, Brendan
Hogan, Monica, Duursma, Louise & Hansson, Dale, Breastfeeding
and breast milk: vital for our species 9(3): 38-40
Hollebone, Keith, Reflections on my initiation into the secret world of
complex vaginal birth 11(4): 14-15
Homan, Louise, [Further perspectives on should medical students
deliver babies] 10(1): 38
Horsfall, John, Dr Charles Anthony Barbaro [obituary] 10(3): 85
Howat, Paul See de Costa, Caroline
Howat, Paul, Another extreme O and G experience 8(3): 56-57
Howat, Paul, Does the College need a representative group for
salaried staff specialists? [Points of View] 7(2): 11
Howat, Paul and Scherman, Samantha, Moving towards trust and
cooperation in obstetrics 9(2): 21,52
Howat, Paul, Obesity in pregnancy 10(4): 10-11
Howat, Paul, Training supervisors speak: is the apprenticeship
model of O and G under threat? 7(2):14
Howlett, Donna See Kovacs & Rutherford
Hughes, Chris, Improving the process of advanced surgical skills
7(1): 33
Hugo Graeme, Recent trends in Australian fertility 9(2): 11-13
Humphrey, Michael, MRANZCOG exam: oral examination
summary 7(2): 40-41
Hutton, John, Raffaela Angela Buonocore [obituary] 7(4): 76-77
Huxley, Rachel and Anna, Vibeke, Matters of the heart are important
to women 10(3): 13-14
Iyengar, Vasu, Namaste India: Indian women and health 10(2):

16-19
Jackson, Chris, What can science teach us about prayer? 10(2):

35, 37
Jacobson, Tal, How toperform a safe Veress needle laparoscopic
entry 11(2): 47-50
Jansen, Robert, Reproductive issues in 2026 will go back to 1986
8(1): 23-26

Jansen, Robert & Gee, Alison, Testing for miscarriage 10(2): 48-52
Jayasinghe, Daya See Jayasinghe, Yasmin
Jayasinghe, Yasmin, Eames, Mai & Jayasinghe, Daya, A Buddist
perspective on womens health issues 10(2): 11-13
Jenkins, Greg & Nanayakkara, Susie, Female genital mutilation
10(2): 29, 31-32
Jequier, Anne, Male infertility: a nightmare for the gynaecologist
and the patient [Points of View] 7(3): 14-15
Jobling, Tom See Manolitsas, Tom
Jones, Ron, Gynaecological club 8(4): 56
Jones, Ronald & Cooper, Michael, John Heywood Taylor [obituary]
11(3): 90-91
Jones, Warren, A road less traveled 10(1): 21
Jotkowitz, Max, [Points of View] 9(4): 70
Kaladelphos, George & Barry, Christopher, A Visit to Chennai,

India: Kasturba Ghandhi Hospital 7(3): 49
Katz, Steven, Anaesthesia for the obese parturient 10(4): 29-31
Keaney Megan, A finding for the defence (9)1: 30-31
Kennedy, Elizabeth, Abortion laws in Australia 9(4): 36-37
Kennedy, Elizabeth [Q&A] 10(2): 58-59
Kelleher, Robyn, A holistic approach to the care of parents
experiencing perinatal death 11(1): 32-33
Kern, Ian See Weisberg, Edith
Khadra, Mohammed, Fantasies for the future: simulations and
surgery in 2025 7(1): 19
Kiesey, Calding, Natalie, Minor maladies of pregnancy: a
pregnant obstetricians perspective, 8(4): 10-13
Kiesy-Calding, Natalie, Three deaths in six months: one registrars
experience 11(1): 11-12
King, James, Monitoring maternal mortality and morbidity in
Australia 11(1): 21-22
King, Rosie, Doctor, where did my libido go? 8(3): 9-10
Kirby, Christine, John Francis Kerin [obituary] 8(3): 85
Knight, David See Narayan, Rajit
Knight David, How toperform a standard vaginal hysterectomy
9(2): 39-43
Koelzow, Heike, See Stedman, Wade
Kovacs, Gabor T, Rutherford, Anthony J & Howlett, Donna, Fertility
preservation for women 8(1): 12-14
Kovacs, Gab, Gynaecology management update: polycystic ovaries
& polycystic ovarian syndrome 7(4): 41-43
Kovacs, Gab, The history of IVF: 35 years of human-assisted
reproduction from 1973 to 2008, 9(4): 10-11
Kovacs, Gab, Implanon removals: some advice for when the
Implanon rod is hard to palpate 7(4): 46-47
Krause, Hannah See Goh, Judith
Krause, Hannah, The Silent tragedy in Africa 11(3): 58-59
Krieger, Mark, Authors reply [Points of View] 7(1): 12
Lam, Carl See OShea, Robert

Lam, Peloong See Grover, Sonia
Larsen, Stephen See Bryant, Christian
Leader, Leo See Robson, Steve
Lichter, Maurie, Michael John Jeffares [obituary] 7(4): 76
Lickiss Norelle, Palliative care for the older woman (9) 1: 26-28
Lo, Chern, The incompetent cervix 11(2): 30-32
Longmore, Peter, Some lessons learnt: Fiji 7(3): 51-52
Longmore, Peter, On assignment in the UAE 9(3): 59-61
Love, Clem, Janette (Netta) Galloway Cowie [obituary] 10 (3): 86
Lowe, Sandra, Nausea and vomiting in pregnancy, 9(4): 23-25
Lowe, Sandra, Thyroid disease and pregnancy, 8(4): 26-27
Lowy, Michael, Disorders of male sexual function 8(3): 30-31
Lucas, Noel, Terence McGovern [obituary] 9(4): 82
Macdonald, Fiona, Colin Ferguson Macdonald [obituary] 11(3): 90

MacLean, Norman E, Graeme David Henderson [obituary] 8(3): 86
MacLennan, Alistair See Norman, Rob
MacLennan, Alistair, Hankins, Gary & Michael Speer, Only an
expert witness can prevent cerebal palsy 8(1): 28-30
Macnab Francis, The sexual concerns of the older women (9)1:
24-25
Macnab, Francis, Sexual counselling: a common problem 8(3): 29,
31
Macnab, Francis, Some considerations of breast cancer the
psychological impact 9(3): 34-35
Maher, Christopher See Frazer and Rane
Mahmood, Afza, Giorgio, Bruno & Scroggs, Steven, Working to
prevent maternal mortality in Timor Leste 11(1): 64-66
Mann, Linda, Why is the GP off the radar in the institutional mind?
[Points of View] 7(1): 13
Manolitsas, Tom & Jobling, Tom, The merits of laparoscopic surgery
in gynaecological oncology 7(1): 28-29
Marrinan, Clem, Desmond James Dooley [obituary] 8(3): 85
Marsden, Donald, Further reflections on maternal mortality in Laos
11(3): 60-62
Marsden, Donald & Henry, Amanda, Postpartum haemorrhage:
when the oxytocics fail 8(4): 30-31
Marsden, Donald, A scientific meeting in Laos 10(3): 65-67
Martinez, Gabriel, Shirley Blyth Robertson [obituary] 8(3): 87
Matthias, Gamal, Immune interactions and tolerance between
mother and embryo 9(4): 14-17
McBride, William, [Q&A] 9(3): 73
McCowan, Leslie & Groom, Katie, Recognition and management of
SGA pregnancies 9(3): 74-79
McInerney, Robert JF, Gwendoline Gerrard [obituary] 8(4): 68
McKenna, Elizabeth, Setting up private practice: pleases, challenges
and pitfalls 7(2): 53-54
McLennan, Andrew See Siva, Sashi
McLintock, Claire, Thrombophilia and obstetrics 11(3): 21-23
McNamee, Heather, Pap smears and general practice: times they
are a-changing 7(3): 30
Meagher, Simon, Antenatal diagnosis of fetal heart malformation: at
11 to 14 weeks gestation 10(3): 36-41
Mellor, Amy, Routine antenatal screening 11(2): 13-15
Mellor, George P See Airey, Yvonne
Merkur, Harry, Nick Biswas [obituary] 8 (3): 87
Mildenhall, Lindsay, Neonatal resuscitation 8(4): 28-29
Miller, John, Gynaecological oncology in the elderly 9(1): 15
Miller, Marc, Postnatal debriefing 7(4): 21
Miller, Marcus See Christie, Damian
Mohen, Diane, Rural obstetric services: by whom, how and where
will be delivering babies in 20 years time? 8(1): 16-17
Mohiuddin, Seema See Tan, Ai-Ling
Mola, Glen, Caring for pregnant women with donavanosis or HIV in
the low-resource setting of Papua New Guinea 7(3): 22-24
Mola, Glen, Maternal mortality in Papua New Guinea 11(1): 34-36
Molloy, David, In praise of academics: perspectives from private
practice 10(1): 16, 18
Montgomery, Robin, Moving New Zealand training forward: where
to from now? 7(2): 20
Moore, Paddy, Practical management of precocious and delayed
puberty in girls 8(3): 22-25,35
Morris, Norman, From Carins to Dharan [including nine interesting
cases] 8(1): 73-80
Morris, Norman, In the shadows of Kanchenjunga: a health camp
in eastern Nepal 8(2): 78-80
Morrison, Barbara, William Morrison [obituary] 10(1): 95
Moser, Clare, The anaesthetic management of postpartum
haemorrhage 11(3): 30-32
Mourik, Peter, Are you considering retirement? 10(2): 64-65

Mourik, Pieter, Memoirs of a SOLS locum (9) 1: 52-53
Mourik, Pieter, Teaching O and G in PNG 9(3): 56-57
Mourik, Pieter, What lessons can Australia draw from the New
Zealand maternity care experience? 7(3): 36
Muller, Peter, Improving ultrasound skills for trainees: the South
Australian experience 7(2): 33-35
Munday, Robert, Surgery under hypnosis 8(2): 19
Murray, Sue, Breast cancer in Australia today: an overview of breast
cancer by the National Breast Cancer Foundation 9(3): 9-11
Nagel, Tricia, Remote mental health: Indigenous women of the Top

End 7(4): 23-25
Nanayakkara, Susie See Jenkins, Greg
Narayan, Rajit and Knight, David, Menorrhagia 11(3): 51-53
Neppe, Cliff [Q&A] 11(2): 55-56
Newham, John, Periodontal disease: a cause of preterm birth 7(3):
19
Nicholl, Michael, Using clinical practice improvement methodology
to reduce perineal trauma 9(1): 54-55
Nisselle, Paul, Is there risk when trainees work in your private
practice? 10(1): 56-57
Nolan, Chris, Diabetes in pregnancy: it is not a benign condition
8(4): 37-38
Norman, Mark, Lance Ernest Norman [obituary] 9(2): 58
Norman, Rob & MacLennan, Academic O and G in Australia and
New Zealand 10(1): 10-11
Obermair, Andreas, A randomised trial: laparoscopic approach to

carcinoma of the endometrium 7(4): 60,72
OBrien, Margaret, Ten years of bush O and G in the Top End
8(2): 20-21
OConnor, Vivienne, O and G undergraduate education: the
medical course, subsequent training and practice 7(2): 12-13
OConnor, Vivienne, Teaching and learning with simulated patients
10(1): 41-42
Otton, Geoffrey, You reap what you sow: how to prepare for the
examinations 7(2): 39
Oke, Kay, Infertility and IVF treatment: an emotional rollercoaster
7(4): 28-30
Olive, Emily, [Points of View] 9(4): 70
Olle, Liz, A lifetime of violence: older women and mental health
7(4): 33-36
OShea, Robert & Lam, Carl, Laparoscopic surgery in obese patients
8(2): 14-15,68
OShea, Robert, The view from the ages: the future of
gynaecological surgery 7(1): 20-21
OSullivan, Brendan, Bushati, Tony & Ho, Tim, Homebirth transfers
at Lismore Base Hospital: a retrospective review 11(4): 31-33
Owens, Julie See Robinson, Geoffrey
Page, Ian, [Points of View - An untimely delivery? PPROM] 9(2): 57

Page, Ian, [Points of View - Antepartum haemoorhage] 9(2): 57
Palmer, Di, FLP: physiology and endocrinology of peri- and
postmenopausal women 7(2): 26
Palmer, John, [an interview with] FLP: medical ethics 7(2): 28
Parekh, Vanita See Devine, Bronwyn
Parker, Malcolm, Posthumous sperm procurement and conception:
ethical reflections 9(4): 48-49
Parmar, Ramesh See Cooper, Steve
Parry, Emma, Blood and the fetus 11(3): 24-26
Parry, Emma, Managing PROM and PPROM 8(4): 35-36, 38
Parry, Gordon & Crowley, John, Gordon Cumming [obituary] 7(3):
71
84 O&G Magazine
Parry, Graham, Journeys of a fetal red cell 10(3): 28-29

Patel, Anushka See Cordina, Rachael
Peach, Hedley, John Garland Griffiths [obituary] 7(2): 74
Pearn, John, Gordon Young [obituary] 8(3): 86-87
Pecoraro Gino, Climate change for urban obstetricians 9(2): 19, 63
Peek, Michael, Antepartum haemorrhage (9)1: 36-38
Permezel, Michael, MRANZCOG exams: short answer question
feedback 7(2): 42
Permezel, Michael [Q&A] 11(4): 53
Permezel, Michael, VMOs, staff specialists and academics:
symphony or disharmony? 10(1): 12-14
Pesce, Andrew, Planned homebirths in Australia: art, scienceor
politics? 11(4): 29-30
Petersen, Rodney & Quinlivam Julie, The Notre Dame mentoring
model: teaching obstetrics and gynaecology in a new medical
school 10(1): 39-40
Pettigrew, Ian, Ectopic pregnancy 8(4): 47
Pettigrew, Ian, Summary of the Diploma oral examination April
2005 7(2): 51-52
Pfanner, David, Ian Douglas Truskett [obituary] 10(3): 85
Phillipson, Greg, Male fertility: a case for more or less science?
8(3): 17
Potter, Andrew, Bleedin obstetrics 11(3): 27-29, 32
Priest, Daniel, Shoulder dystocia is not always shoulder dystocia
11(2): 65-66
Quested, Bev, Administration of RhD immunoglobulin to prevent

maternal Rhesus all immunisation 11(3): 19-20
Quinlivan, Julie See Petersen, Rodney
Quinlivan, Julie, Teenage pregnancy 8(2) ; 25-26
Quinn, Frank, Oocyte donation in assisted conception, 9(4): 12-13
Rane, Ajay See Frazer and Maher

Rane, Ajay, Geripause and the pelvis 9(1): 16-17
Rane, Ajay, Pelvic surgery and sexual dysfunction 8(3): 11-12
Rane, Ajay, Why would anyone be an academic? 10(1): 18
Ranka, Poornima & Adair, Steve, The heart of pregnancy 11(3):
13-14
Raymond, Steve, Death in gynaecology: experiences in South Africa
11(2): 62-63
Reilly Aimee, [Q&A] 11(1): 48-49
Richmond, David, How does the GP obstetrician maintain surgical
skills? 7(1): 45
Ridley, William [Q&A] 9(2): 54
Roberts, Tom, Ian Kenneth Mayes [obituary] 10(3): 75
Robertson, Rosalind, Psychological issues facing women with
gynaecological cancer 7(4): 31-32,
Robertson, Struan, Reginald Bowman [obituary] 11(2): 91
Robinson, Geoffrey & Owens, Julie, The early life origins of health
and disease 9(4): 18-21
Robson, Steve See Subramaniam, Peter
Robson, Steve See Daniels, Brett
Robson, Steve See de Costa, Caroline
Robson, Steve See Schibeci, John & Chinnock, Marian
Robson, Steven, Back to basics [editorial] 8(4): 8
Robson, Steve, Childbirth in 2026 [editorial] 8(1): 9
Robson Steve, Climate change [editorial]9 (2): 9
Robson, Steve, Does the heart go on? 10(3): 50
Robson, Steve, Everyones a critic [editorial] 11(4): 11
Robson, Steve, Going to extremes in pregnancy [editorial] 8(2): 8-9
Robson, Steve, How to perform a standard abdominal
hysterectomy 10(1): 47-50
Robson, Steve, The journey to viability [editorial] 9(4): 9
Robson, Steve, Some insights into the epidemiology of obesity
10(4): 37-38

Robson, Steve & de Costa, Caroline, Forceps delivery: science
wears its art on its sleeve 11(4): 19-20
Robson, Steve & Leader, Leo, Unexplained stillbirth 11(1): 28-31
Robson, Steve, What does the future hold for gynaecological
surgery? [editorial] 7(1): 17
Rome, Robert, Low grade abnormalities: the clinicians dilemma
[Points of View] 7(4): 11-12
Rosen, Derek, A different world 9(1): 78-79
Russell Darren, Do older women still have sex? (9) 1: 22-23
Rutherford, Anthony See Kovacs & Howlett
Said, Joanne, Managing pre-eclampsia 8(4): 43-44

Sartain, James, Obstetric patients with rheumatic heart disease
10(3): 18-20
Saunders, Cliff, Ethical aspects of screening and diagnosis
chromosomal and other abnormalities in the second trimester
11(2): 28-29
Saunders, Douglas, John Leaver [obituary] 9(4): 83
Schaefer, Glenn, John James Morrissey [obituary] 10 (3): 74
Schibeci, John, Obesity [editorial] 10(4): 9
Schlipalius, Michelle, Twinning: a two-way learning experience with
Vanimo, Papua New Guinea 11(3): 65-66
Scherman, Samantha See Howat, Paul
Schibeci, John [collected by], Non-pharmacological pain
management in childbirth 11(4): 25-28
Schibeci, John, Chinnock, Marian & Robson, Steve, Term breech
delivery 9 (2): 46-49
Schibeci, John, Will GPs still be delivering babies in 2026 8(1): 21
Schramm, Mary [Points of View] 9(2): 56
Schroeder, David, Why are you big and I am not? Understanding
the obese patient 10(4): 21-22
Scott, Jennifer, Ovarian health study 8(3): 47-48
Scott, Peter, Elite sports performance and reproductive problems
8(2): 22-23
Scroggs, Steven See Mahmood & Giorgio
Seman, Elvis, Pelvic reconstructive surgery: what does the future
hold? 7(1): 24-25
Shand, Carol See Sparrow, Margaret
Sharp, Graeme, Stewart, Adrian, Brian Morrison Corkill 7(3): 70-71
Sharpe, Norman, Womens heart health: a case of neglect 10(3):
11-12
Sherwood, Rupert, Resucing academic O and G: the role of
RANZCOG committees 10(1): 19-20
Siva, Sashi & McLennan, Andrew, The impact of obesity on
obstetrical and gynaecological ultrasound 10 (4): 26-28
Skipper, John, Leslie Poi Devin [obituary] 9(2): 58
Sloss, Bill, William Sloss [obituary] 9(4): 84
Sly, Jason, Surgery under headlights 11(3): 55-57
Small, Kirsten, Giving birth in Iran 10(1): 61-65
Smalldridge, Jackie, Whats new in urinary incontinence? 11(2):
42-43
Snellen, Martien, Sex and intimacy after childbirth 8(3): 13-15
Snellen, Martien & Galbally, Megan, Mental illness and antenatal
care 7(4): 15-17
Solomon, John, Francis Paton Pigott [obituary] 7(1): 67
Somerset, David, The emergency management of catastrophic
obstetric haemorrhage 8(4): 18-22
Southall, Donald, Ian Maxwell [obituary] 9(4): 84
Souter, Dereck, Postpartum haemorrhage and post-traumatic stress
disorder 11(3): 38-39
Sowter, Martin, Complex vaginal deliveries: why are we still doing
them? 11(4): 17-18
Sowter, Martin, Managing menorrhagia 8(4): 45-46
Sparrow, Margaret & Carol Shand, Abortion in New Zealand 9(4):
29-30
Speer, Michael See MacLennan & Hankins
Spreer, Alicia see Gilberg, Miranda

Stafford-Bell, Martyn, Social infertility 8(3): 25-26
Stedman, Wade & Koelzow, Heike, Swine flu in obstetrics 11(4):
40-41
St Martin, Leena, Chronic pelvic pain and complex pain behaviours:
a model for multidisciplinary care 8(3): 32-35
Stewart, Adrian See Sharp, Graeme
Stewart, Ian, Kenneth John Rew [obituary] 8(1): 34
Stewart, Tanya & Baker, Gordon, The inverse relationship between
obesity and testicular function10(4): 34-36
Stone, Peter, Dennis Geoffrey Bonham [obituary] 7(3): 69
Stone, Peter, Late termination of pregnancy 9(4) 31-32
Stone, Peter, Termination of pregnancy in New Zealand: a womanfocused service 7(1): 55-57
Stonestreet, Jenny, The GP obstetrician and the midwife: a rural
midwifes perspective 9(2): 24
Stretch, Jonathan See Ford & Hartman
Strong, Birgit See Christie, Damian
Subramaniam, Peter & Robson, Steve, Heart transplant and
pregnancy 10(3): 32-35, 24
Sullivan, Elizabeth & Biggs, Janice, Australian maternity outcomes
surveillance system (AMOSS) 10(3): 56-57
Sullivan, Gerard, Obstetrics engineering: a curious historical note
8(2): 54-55
Svigos, John, Heather Ross [obituary] 9(3): 91-92
Svigos, John & Antonas, Basil, Hugo Ulrich Herbert von Alpen
[obituary] 11(4): 74
Swain, Michael See Verdoom, Nadine
Tan, Ai-Ling & Mohiuddin, Seema, Obesity and surgery in

gynaecology oncology 10(4): 32-33
Taylor, Jeff, Climate change for GP obstetricians 9 (2): 17-18
Taylor, Jeff, Is there a place for the academic GP obstetrician?
10(1): 29
Thomas, Adrian, Matercare International 8(2): 74-75
Thomas, Ifor Llewelyn, Robert John Buck 10(3): 75
Teh, Wan Tinn & Stephen Tong, Intrapartum fetal monitoring:
yesterday, today and tomorrow 11(4): 36-37
Thomas, Adrian, James Boyer Brown [obituary] 11(4): 70
Todman, Don, A tribute to the late Dr John Billings, creator of the
Billings ovulation method [obituary] 10(1): 68
Tolcher, Debbie & Wilkinson, Shelley, Beyond dieting: innovative
dietetic management of obese pregnant women 10(4): 19-20
Tong, Stephen See Teh, Wan Tinn
Tonti-Filippini, Nicholas, Professional conscience 10(2): 27-28
Took, Andrew, Informed consent in labour: Australian perspective
11(4): 58-61
Torode, Hugh, Ian McNaughton Kelso [obituary] 8(3): 84
Tout, Sarah, Blood [editorial] 11(3): 11
Tout, Sarah, Extreme prematurity 8(2): 31-32
Tout, Sarah, The heart of the matter [editorial] 10(3): 9
Tout, Sarah, Maternal death: a collection of personal experiences
[collected by] 11(1): 13-20
Tout, Sarah & Court, Denys, A New Zealand response to the
medico-legal article on elective caesareans [letters to the editor]
11(1): 52
Tout, Sarah, [Q&A] 8(1): 53
Trivedi, Amarendra Nath, Expert witness testimony: how should you
prepare? 7(1): 61-62
Tucker, Kathy, The gynaecologist and breast and ovarian cancer: the
complex genetics of breast cancer 9(3) 22-25
Ung, Owen, Breast cancer management 9(3): 12-17

Uppal, Talat & Ogwu, Chris, The curse of sickle cell disease 11(3):
40-41
Subject Index: Volume 7 to Volume 11

V
Subject Index
Vaughan, Janet, Misplaced faith in the 20-week morphology scan

11(2): 35-37
Vaughan, Ron, [Q&A] 8(3): 40
Vellar, Ivo, Francis Joseph Hayden [obituary] 7(3): 71
Verco, Chris, Flying mum 8(2): 27
Verdoorn, Nadine & Swain, Michael, Feto-maternal haemorrhage
estimation 11(3): 33-35
Volumes 711, 2005-2009
The following abbreviations have been used:

O & G = obstetrics and gynaecology
Wadsworth, Sarah, Investigations at stillbirth 11(1): 26-27

Wain, Gerry, FLP: Oncology, dysphasia & vulval disorders 7(2): 25
Wall, Madeline, BreastScreen Aotearoa: New Zealands breast
cancer screening program 9(3): 20-21
Wallis, Dee, Torches, teamwork and terrain: the life of a mobile
womens health nurse 7(3): 34-35
Walters, Barry, Obstetric management update: venous thrombosis
and embolism in pregnancy 7(4): 44-45
Walters, William, Enid Menary Carey [obituary] 10(3): 73
Warry, Louise, Pap smear: reminders and recalls 7(3): 31, 33
Watson David, Soft markers in ultrasound (9)1: 45, 49
Weaver, Ted [Q&A] 8(4): 64
Weaver, Ted, Hand-held Doppler machine use at home by nonhealth professionals 10(4): 45
Weaver, Ted, Robertson, Ann & Miller, Cal, Patient education is best
when its a process 9(3): 62-63
Wein, Peter, Orthodox Judaism and womens health 10(2): 20-22
Weisberg, Edith & Kern, Ian, A further overview on Judaism and
womens health 10(2): 23, 26
Welsh, Toni, Controlling the timing of labour: the role of
progesterone and prostaglandins 11(4): 38-39
Westgate, Jennifer, FLP: Fetal physiology 7(2): 24
Weston, Gareth, Obstetrics Capetown-style 8(4): 78-79
Weston, Gareth, Providing trainees with the right tools of the
practising trade 7(2): 18
White, Pete, Demystifying the RANZCOG examinations 7(2): 36-38
Wilkins, Danielle, Now why would anyone want to be an
obstetrician? 7(1): 49
Wilkinson, Chris, By whom, how and where will we be delivering
our babies in 20 years time? 8(1): 19
Wilkinson, Shelley, See Tolcher, Debbie
Wilson, John, Twins twins head-to-head 8(2): 12-13
Woods, Peter, Candid thoughts of a trainee: is there a better way to
train us? 7(2): 19
Yared, Len, Stephen Broe [obituary] 7(3): 69-70

Yazdani, Anusch, Open gynaecological surgery: are trainees being
sufficiently educated in this area? 7(1): 34-35
Younis, Huda, Islam and bioethics 10(2): 24-26
Zipser, Gabriel, John Michael Skalicky [obituary] 7(4): 76
86 O&G Magazine
Volume numbers will appear first in index entries, issue numbers

in brackets afterwards and page numbers following: for example,
10(1): 18 = Vol 10, No 1, page 18.
Articles A, In and The are ignored in filing entries.
Series names and editorials have been placed in square brackets [ ].

For example, Cervical cancer, postcoital bleeding [Q&A] 11(3): 54
[Q&A] refers to an article from the Q&A series.
[Points of View] refers to an article from the Point of View series.
*Articles written about working in overseas countries have been
indexed under the place name. For example, Gambia, West Africa
9(1): 78-79.
Abortion
abortion services - New Zealand 9(4): 29-30
abortion services - Australia 9(4): 27-28
editorial 9(4): 26
expenses and costs for women in the rural region 7(1): 58-60
interpretation of laws and legislation 7(1) ; 52-54
legislation - Australia 9(4): 36-37
legislation - New Zealand 7(1): 55-57
rates in Australia, need for more monitoring 7(1): 50-51
rural services, lack of 7(1): 58-60
Academic medicine See also medical education and education,
continuing
career in, personal reflection 10(1): 21
GP obstetrician 10(1): 29
issues affecting lack of academics in obstetrics and gynaecology
10(1): 18
mentoring model Notre Dame School of Medicine 10(1): 39-40
O & G as a specialty 10(1): 10-11
O & G in Australian and New Zealand 10(1): 10-11
private practice and academia, the divide 10(1): 16, 18
role of RANZCOG committees 10(1): 19-20
rural obstetrics, interaction with 10(1): 22, 24
Academic Research
research project, trainee personal reflection 10(1): 25
role of RANZCOG in trainees developing research skills 10(1):
23-24
tales from a trainees research project 10(1): 25
Adolescence
obesity epidemic 10(4): 24-25
teenage pregnancy 8(2): 25-26
sexual relationship of a 14-year -old [Q&A] 10(2): 58-59
Adult diseases, common
effects on fetal development 9(4): 18-21
Air travel
pregnancy and guidelines 8(2): 28-30
pregnancy in pilots and passengers 8(2): 27
Anaemia
in pregnancy 11(3): 17-18
in the fetus 11(3): 24-26
Anaesthesia
hypnosis 8(2): 19
obese parturient, for 10(4): 29-31
Antarctica
womens health 8(2): 16-18

Antenatal care
Australia (patients perspectives) 11(4): 24
mental illness 7(4): 15-17
New Zealand (patients perspective) 11(4): 24
standards 11(4): 22-23
Antenatal depression
antidepressants and effect on fetus 7(4): 18-20
Antenatal screening 11(2): 13-15
Antepartum haemorrhage
handy hints 9(1): 36-38
Apprenticeship model of O & G 7(2): 14
Assisted reproduction
posthumous sperm procurement 9(4): 48-49
Asylum seekers
psychological assessment 7(4): 56-57
Auckland group practice 8(1): 10
Australian College of Midwives
code of ethics 9(2): 24
conference, 2006 9(2): 15-16
Australian Society for Psychosomatic O & G (ASPOG) 8(3): 27
Baby boom
editorial 8(4): 8
Birth plans
[Q&A] 11(4): 53
Birth population
statistics 9(2): 11-13
Blood
circulation, in fetus 11(3): 24-26
editorial 11(3): 11
historical account 11(3): 42-44
Blood clots See Thrombophilia
Brazilian waxing 8(3): 20-21
Breast
plastic and aesthetic surgery 9(3): 31-32
Breast cancer
genetics and genetic testing 9(3): 22-25
organisations 9(3): 9-11
psychological impact 9(3): 34-35
personal experience of survival 9(3): 36-37
Breast milk 9(3): 38-40
Breast pain 9(3): 26-27
Breast reduction surgery
patients perspective 9(3): 33
Breast screening
women in rural area 9(3): 18-19
Breastfeeding 9(3): 38-40
Breech delivery
obstetric management update 9(2): 46-49
[Q&A] 11(2): 55-56
Burch colposuspension 8(2): 19
Caesarian deliveries
difficult 8(1): 54-55
elective [Q&A] 9(4): 50
elective 11(1): 52
obese patients 10(4): 10-11
vaginal delivery, prominence over 11(4): 14-15
Cancer See Specific e.g. Gynaecological Cancer, Cervical Cancer
etc.
Capetown, South Africa 8(4): 78-79

Cardiac disease
management and risks in pregnancy 10(3): 21-24
New Zealand women 10(3): 11-12
pre-existing condition, management in pregnancy 11(3): 13-14
treatment of pregnant women with congenital heart conditions
11(3): 13-14
Cerebal palsy
expert witness 8(1): 28-30
legal case 9(1): 30-31
Cervical cancer
postcoital bleeding [Q&A] 11(3): 54
Cervical lesion, management [Q&A] 10(2): 57
Cervix, incompetent
diagnosis and management 8(4): 16-17
overview 11(2): 30-32
Chickenpox [ Q&A] 9(3): 73
Child
obesity epidemic 10(4): 24-25
Childbirth
editorial 8(1): 9
future of [Points of View] 8(2): 3
pain management 11(4): 25-28
Chromosomal abnormality
ethical aspects 11(2): 28-29
sex chromosome aneuploidy 11(2): 25-27
Climate change
editorial 9(2): 9
Clinical midwifery educator, Royal Darwin Hospital 10(1): 36-37
Congenital heart disease
diagnosis in fetus by ultrasonic imaging 10(3): 30-31
management and risks in pregnancy 10(3): 21-24
Conjoined twins 8(2): 12-13
Consultations
for the older women 9(1): 11-12
Contraception
reproductive issues 2026 back to 1986 8(1): 23-26
sperm procurement 9(4): 48-49
Contraception devices
implanon rod 7(4): 46-47
Coronary artery disease
diagnosis of women with atypical and typical symptoms 10(3):
15-17
Counselling
parents experiencing perinatal death 11(1): 32-33
parents in premature infants 11(2): 33-34
Craniopagus twins 8(2): 12-13
Cyropreservation 8(1): 12-14
Death See also Maternal deaths

identifying symptoms and management of approaching death
11(1): 43-44
practitioner in your practice 11(1): 50-51
Delivery of babies
future predictions 8(1): 15
futuristic look at 2026 8(1): 19
GPs delivering in 2026 8(1): 21
homebirth, New Zealand 11(4): 34-35
homebirth, politics of 11(4): 29-30
homebirth, hospital transfer 11(4): 31-33
medical students 10(1): 30-35
normal delivery over caesarean [Q&A] 8(2): 71
obese women 10(4): 14-16
PPROM [Points of View] 9(2): 57
rural services, future predictions 8(1): 16-17
Detention centres 7(4): 56-57

Dharan, Eastern Nepal 8(1): 73-80
Diabetes
identifying risks for women 10(3): 13-14
Diagnostic ultrasound See also Ultrasound fetal imaging
entertainment 8(4): 54-55
skills for trainees in South Australia 7(2): 33-35
Dietetics
Five as approach, Mater Mothers Hospital 10(4):19-20
role in management of obese pregnant women 10(4): 19-20
Diplomates
workforce crisis 9(2): 17-18
Disorders of sex development (DSD) 8(3): 18-19
Doctor-patient communication
HIV positive, during infertility treatment 8(1): 58-59
sensitivity to obese pregnant patients about good health and
wellbeing 10(4): 17-18
Domestic violence
psychological issues 7(4): 33-36
Doppler machine, use at home 10(4): 45
Down syndrome
counselling of parents and families 11(2): 17-19
nuchal translucency screening 9(4): 38-41
personal narrative 11(2): 20-21
soft markers in ultrasound 9(1): 45, 49
Early pregnancy loss

management 9(2): 33-35
Eclampsia, prevention [Letter to the Editor] 11(4): 21
Education See Academic Medicine; Education, Continuing; Flexible
Learning Program and Medical Education
Education, Continuing
Diplomates 9(2): 17-18
Flexible Learning Program (FLP), tools of the trade 7(2): 18
German training system compared with Australian training system
7(1): 36, 46-47
maintaining specialist registration 9(2): 19, 63
O and G training in New Zealand, 7(2): 17
pros and cons of the College training model 7(2): 15-16
womens health as a discipline 7(2): 12-13
rural general practitioners, continuing professional development
in obstetrics 7(1): 45
trainees individual assessment of the RANZCOG curriculum
7(2): 19
workshops in basic skills 7(2): 62-63
Elective caesareans 11(1): 52
Embryo
storage and preservation 8(1): 12-14
Emergency obstetrics See Obstetrics, Emergency
End of life See also Death
Identify and providing care of 11(1): 43-44
Endometrial ablation 9(3): 42-45
Epidemiology
obesity, factors in 10(4): 37-38
origins of health and disease 9(4): 18-21
Egg donors 9(4): 12-13
Emergency obstetrics
Endometriosis
clinical approach to 9(1): 46-49
surgery, alternatives and surgical skills needed in the future
7(1): 22-23
Endometrium
tamoxifen therapy [Points of View] 7(1): 15, 80
Ethics
bioethics, influence of Islam 10(2): 24-26
88 O&G Magazine
professional conscience 10(2): 27-28

report, sexual relationship of 14-year-old girl [Q&A]
10(2): 58-59
sperm procurement 9(4): 48-49
Exams See Examinations
Examinations
College examinations, preparation of 7(2): 39
Diploma Oral examination 7(2): 51-52
MRANZCOG, oral summary 7(2): 40-41
MRANZCOG, short answer feedback 7(2): 42
Exercise and fitness
preconception care 9(4): 21-22
External cephalic version (ECV) 9(2): 46-49
Extreme prematurity (EP) 8(2): 31-32
Female fecundity 9(1): 18-19

Female genital mutilation 10(2): 29,31-32
Fertility rates
Fetal circulatory system
blood, circulation and 11(3): 24-26
physiology of 10(3): 28-29
Fetal death See Perinatal death
Fetal fibronectin (fFn) 8(3): 39
Fetal growth restriction 9(3): 74-79
Fetal heart diseases
cardiac anomalies 10(3): 30-31
cardiac malformation 10(3) 36-41
Fetal monitoring 11(4): 36-37
Feto-maternal haemorrhage 11(3): 33-35
Fiji 9(3): 58-59
First trimester
detecting fetal cardiac malformations 10(3): 36-41
editorial 9(4): 9
immune interactions 9(4): 14-17
Fistula See Obstetric fistula
Flexible Learning Program
anatomy and embryology 7(2): 22
cultural and womens health 7(2): 29
epidemiology and statistics 7(2): 27
fetal physiology 7(2): 24
haematology and pathology 7(2): 23
infectious diseases and microbiology 7(2): 24
oncology, dysphasia and vulval disorders 7(2): 25
medical ethics 7(2): 28
overview 7(2): 21
physiology and endocrinology of peri- and postmenopausal
women component 7(2):26
tools of the trade 7(2): 18
trainees personal experience 8(1): 69-70
FLP See Flexible Learning Program
Future directions for maternity care 8(1):15
Gambia, West Africa 9(1): 78-79

General practice,
academic GP obstetrician 10(1): 29
involvement in patient care [Points of View] 7(1): 13
obstetrics services in 2026 8(1): 21
rural, continuing professional development in obstetrics 7(1): 45
Genital prolapse 9(1): 16-17
Genitalia, ambiguous 8(3): 18-19
Geripause 9(1): 16-17
GP Obstetric Advisory Committee (GPOAC) 9(2): 17-18
Grief counselling See Counselling
Group practice

advantages and disadvantages 8(1): 11
solution to burnout, New Zealand 8(1): 10
Gynaecological cancer
endometrial cancer 7(4): 60, 72
laparoscopic surgery and its disadvantages 7(1): 26-27
obese patients and surgery 10(4): 32-33
older women, in the 9(1): 15
potential of laparoscopic surgery 7(1): 28-29
prevention and treatment 9(3): 28-30
psychological issues and assessment 7(4): 31-32, 34
Gynaecological club 8(4): 56
Gynaecological problems
increased risks in obese adolescents 10(4): 24-25
Gynaecological procedures
laparoscopic entry 11(2): 47-50
standard vaginal hysterectomy 9(3): 39-42
Gynaecological surgery
deaths 11(1): 24-25
editorial 7(1): 17
futuristic simulations 7(1): 19
German training comparison with Australian training 7(1): 36,
46-47
hypnosis as an alternative 8(2): 19
interventional radiological procedures as an alternative treatment
7(1): 30-32
surgical training in the future 7(1): 20-21
H1N1 Influenza See Swine Flu

Haemolytic disease
administration of RhD immunoglobulin 11(3): 19-20
Haemorrhage, feto-maternal 11(3): 33-35
Haemorrhage, obstetric 11(3): 27-29, 32
Haemorrhage, postpartum
anaesthetic management 11(3): 30-32
oxytocics fail 8(4): 30-31
resulting in post-traumatic stress disorder 11(3): 38-39
remote hospital 11(3): 36-37
Heart
editorial 10(3): 9
Heart disease See Cardiac disease
Heart transplant
personal recollections of similarities with their donors 10(3): 50
risks in becoming pregnant 10(3): 32-35, 24
Herpes viruses
survey of obstetricians and trainees knowledge 7(2): 31-32
High-risk population
women and gynaecological cancer 9(3): 28-30
Homebirth
hospital transfer, Lismore Base Hospital 11(4): 31-33
midwifes perspective (New Zealand) 11(4): 34-35
[Q& A]8(3): 40
politics 11(4): 29-30
Hormone, progesterone and prostaglandins 11(4): 38-39
Hormone replacement therapy
cardiovascular disease risk 10(3): 48-49
in older women 9(1): 20-21
Hot flushes [Q&A] 10(3): 52-53
HRT see Hormone replacement therapy
Hypnosis
alternative means to anaesthesia 8(2): 19
Hysterectomy
abdominal 10(1): 47-50
vaginal 9(2): 39-42
Implanon rod 7(4): 46-47

Incontinence
urodynamic stress 8(1): 48-49
Indigenous health
mental illness in indigenous women 7(4): 23-25
obstetrics and gynaecology in the Northern Territory 8(2): 20-21
Induction of labour
partner in defence forces [Q&A] 8(4): 64
failed [Q&A] 8(1): 52
Infertility treatment
HIV positive 8(1): 58-59
Intrauterine growth restriction (IUGR) 9(3): 74-79
Iodine supplementation 7(1): 65-66
Iran 10(1): 61-65
ITP research project 7(2): 30, 32
In vitro fertilisation
counselling and counsellors 7(4):28-30
genetic counselling 7(4): 28-30
history 9(4): 10-11
older women, fertility 9(1): 18-19
IVF See In vitro fertilisation
Kalgoorlie 9(1): 52-53
Labour
cerebral palsy births, adhere to standards 8(1): 28-30
complications in obese women 10(4): 14-16
fetal monitoring 11(4): 36-37
midwifery intervention 8(4): 14-15
pain, management of 8(4): 23-25
progesterone and prostaglandins 11(4): 38-39
Lactation, iodine supplementation 7(1): 65-66
Laparoscopic surgery
advantage in gynaecological surgery 7(1): 28-29
carcinoma of the endometrium, treatment of 7(4): 60, 72
disadvantages of procedure in treating gynaecological cancer
7(1): 26-27
obese patients 8(2): 14-15, 68
procedure, [How to] 11(2): 47-50
Libido, lack of 8(3): 9-10
Male fertility 8(3): 17

Male Infertility
obesity, relationship between 10(4): 34-36
Male sexual function, disorders 8(3): 30-31
Marie Stopes International
Real choices: women, contraception and unplanned pregnancy,
key findings 10(2): 38-39
Mastalgia 9(3): 26-27
Matercare International (MCI) 8(2): 74-75
Maternal collapse 8(2): 33-35
Maternal deaths
case studies 11(1): 13-20
editorial 11(1): 10
high order multiple gestations 8(2): 36-37, 56
history of childbed fever 11(1): 45-46
Laos 11(3): 60-62
morbidity and mortality reports , Australia 11(1): 21-22
New Zealand 11(1): 23
obstetric haemorrhage 11(3): 27-29, 32

obstetric haemorrhage 8(4): 18-22
Papua New Guinea 11(1) ; 34-36
postpartum haemorrhage 11(3): 30-32
pre-eclampsia 8(4): 43-44
registrars personal experience 11(1): 11-12
venous thrombo-embolism 8(4): 32-34
Maternal mortality See Maternal deaths
Maternal suicide
perinatal depression 7(4): 13-14
Media, influence on O and G cases 10(2): 62-63, 65
Medical education See also Academic medicine
benefits and disadvantages of College training program 9(2):
25, 74
medical students, training and experience 10(1): 33
research project 7(2): 30, 32
simulated patients, teaching and learning 10(1): 41-42
teaching hospitals, development of obstetrics courses
10(1): 30-35
workshops in vaginal discharges 9(3): 64-68
Medical students
delivering babies 10(1): 30-35
midwives, relationship with 10(1): 38
midwives teaching at Royal Darwin Hospital 10(1): 36-37
Medico-legal
Dr Lee, Dr Frost and the Hills Private Hospital at Mills
9(1): 30-31
expert witness, preparation 7(1): 61-62
labour, informed consent (Australia) 11(4): 58-60
labour, informed consent (New Zealand) 11(4): 60-61
medical students in private practice, risks 10(1): 56-57
Menopause
increase of cardiovascular disease 10(3): 48-49
Menorrhagia
management 8(4): 45-46
overview 11(3): 51-53
Menstruation See also Premenstrual syndrome
endometrial ablation 9(3): 42-45
haemorrhagic 8(4): 45-46
treatment options [Q&A] 10(3): 52-53
Mental health
identification and management in antenatal or postpartum
period 7(4): 15-17
indigenous women 7(4): 23-25
training the specialist 7(4): 53-55
women suffering from domestic violence 7(4): 33-36
Mercy Ships 11(3): 58-59
Miscarriage 10(2): 48-52
Mid-trimester pregnancy loss 8(4): 16-17
Midwifery
deviation from the normal in labour 8(4): 14-15
homebirth 11(4): 34-35
teaching medical students 10(1): 36-37
Midwifery and obstetrician relationship
alliance 9(2): 23
rural perspective 9(2): 24
trust and cooperation 9(2): 21, 52
Miscarriage See Early pregnancy loss
Moliere 11(3): 42-44
Morbidity and mortality reports for maternal deaths in Australia
11(1): 21-22
Morning sickness
treatment and management 9(4): 23-35
Morphology scan
statistical effectiveness of 11(2): 35-37
90 O&G Magazine
National Breast Cancer Foundation 9(3): 9-11

National Heart Foundation
Go Red for Women Campaign 10(3): 13-14
National Working Party for the Management of Viruses in Pregnancy
7(2): 31-32
Nzega, Tanzania 11(3): 55-57
Neonatal deaths See Stillbirth
Neonataology
extreme prematurity 8(2): 31-32
resuscitation 8(4): 26-27
Nepal, Eastern 8(2): 78-80
New Zealand College of Midwives (NZCOM) 9(2): 23
New Zealand health surveys 10(3): 11-12
Northern Territory 8(2): 20-21
NT Australian Integrated Mental Health Initiative 7(4): 23-25
Notre Dame School of Medicine, mentoring model 10(1): 39-40
Obesity
anaesthesia difficulties and management 10(4): 29-31
antenatal patients 11(1): 52
children and adolescents 10(4): 24-25
complications in labour 10(4): 10-11
diabetes in pregnancy 8(4): 37-38
diet and nutrition advice to pregnant women 10(4): 19-20
editorial 10(4): 9
epidemic in New Zealand 8(2): 10
epidemiology 10(4): 37-38
labour and delivery issues 10(4): 14-16
laparoscopic surgery 8(2): 14-15, 68
male reproductive function, issues 10(4): 34-36
in pregnancy 8(2): 10
pregnancy and rural health [Q&A] 10(4): 43-44
surgery for gynaecological oncology 10(4): 32-33
surgical options to reduce obesity 10(4): 21-22
talking to patients about obesity 10(4): 17-18
ultrasound imaging, problems of 10(4): 26-28
Obituaries
Alder, Ronald Milton 7(2): 73
Allen, Peter Sydney 10(1): 95
Balachandran, Vijayaratnam 10(3): 74
Barbaro, Charles Anthony [obituary] 10(3):85
Barnes, Mercia 11(1): 47
Billings, John 10(1): 68
Bowman, Reginald 11(2): 91
Brown, James Boyer 11(4): 74-75
Buonocore, Raffaela Angela 7(4): 76-77
Buck, Robert John 10(3): 75
Carey, Enid Menary 10(3): 73
Cowie, Janette(Netta) Galloway 10(3): 86
Coulthard, Alan 7(2): 73-74
Davidson, Robert Ian 7(2): 74
Deck, Philip Arnold 11(3): 90
Diamond, Robert Andrew 8(4): 68
Ferrier, Alan John 11(2): 91
Foy, Bryan Nelson 8(2): 69
Gerrard, Gwendoline 8(4): 68
Gordon, Ross 10(1): 94
Griffiths, John Garland 7(2): 74
Hinde, Frederick 8(4): 67
Holmes, Noel Clarkson 10(3): 74-75
Jakubowicz, Diana, 9(3): 91
Jeffares, Michael John 7(4): 76
Jones, Cyrus Arvon 10(3): 73
Khan, Innayat 10(3): 85
Kneale, Barry Lee Griffiths 7(1): 66

Leaver, John 9(4): 83
Lilburne, Geoffrey Douglas Roland 9(1): 77
Macdonald, Colin Ferguson 11(3): 90
Maxwell, Ian 9(4): 84
Mayes, Ian Kenneth 10(3): 75
McGovern, Terence 9(4): 82
Michener, Carmel 11(3): 63
Moni, Paul David Victor 10(3): 73 -74
Morrison, William 10(1): 95
Morrissey, John James 10(3): 74
Mellor, George P 9(4): 82
Norman, Lance Ernest 9(2): 58
Pennington, John Colin 7(1): 67
Pigott, Francis Paton 7(1): 67
Poidevin, Leslie 9(2): 58
Ponnuthurai, Charles Emmanuel 9(3): 91
Puflett, Delmont 10(1): 94
Rachow, Philip 9(4): 84
Refshauge, William Dudley Duncan 11(4): 76-77
Rew, Kenneth John 8(1): 34
Richardson, Robert 9(4): 83
Ross, Heather 9(3): 91-92
Sapsford, Lionel 9(4): 82-83
Skalicky, John Michael 7(4): 76
Sloss, William 9(4): 84
Stichbury, Peter Cameron 7(2): 75
Taylor, John Heywood 11(3): 90-91
Tongue, Walter Stewart James 8(4): 68
Troup, James Gavin Amess 8(1): 34
Truskett, Ian Douglas [obituary] 10(3): 85
Von Alpen, Hugo Ulrich Herbert 11(4): 74
Walters, David John (Jerry) 11(3): 91
Obstetric fistula
West Africa placement 11(3): 58-59
Obstetric forceps 11(4): 19-20
Obstetric haemorrhage
emergency management 8(4): 18-22
Obstetric research, effect on religion, ethics, law and human rights
10(2): 33-34
Obstetrical ultrasound
In obese patients 10(4): 26-28
Obstetrics
art or science [editorial] 11(4): 11
management of patients with rheumatic heart disease
10(3):18-20
relationship between SMOs, staff specialists and academics
10(1): 12-14
scientific milestones 11(4): 12-13
Obstetrics, emergency
Amhara region, Ethiopia 10(2): 40-42
Antarctica 8(2): 16-18
maternal collapse 8(2): 33-35
Polynesia 8(2): 11
Obstetrical equipment
history, George and Charlotte Blonsky 8(2): 54-55
Obstetrics and gynaecology
burnout, solutions 8(1): 10
changing work climate [editorial] 9(2): 9
developments and changes in the last 40 years 8(4): 9, 34
major milestones that have influenced research 10(1): 23-24
Nzega, Tanzania 11(3): 55-57
Papua New Guinea 8(3): 56-57
staffing, golden rules of 10(1): 12-14
Occyte donation 9(4): 12-13
Oncology See Specific cancer e.g. Gynaecological oncology
Ovarian cancer
breast and ovarian cancer 9(3): 22-25
epitherial cancer, screening 11(4): 43-45
incidence of ovarian risk 8(1): 12-14
Ovarian health study 8(3): 47-48
Pacific region
teaching 9(2): 64-65
Pain management
childbirth 11(4): 25-28
chronic pelvic pain 8(3): 32-35
managing labour 8(4): 24-25
Pakistan, North West Frontier Province 9(2): 77-70
Palliative care, older women 9(1): 26-28
Pap smears
abnormal [Q&A] 10(2): 57
in asymptomatic Australian women 7(4): 11-12
NHMRC 2005 guidelines [Points of View] 8(1): 47
Paparazzi, influence on O and G cases 10(2): 62-63, 65
Papua New Guinea
extreme O and G experience Papua New Guinea 8(3): 56-57
maternal morality 11(1): 34-36
teaching obstetrics and gynaecology 9(3): 58-59
working vacation 10(4): 64-65
Patient-doctor confidentiality
teenagers 8(3): 80-81, 83
Patient-doctor communication
older women as patients 9(1): 11-12
Patient education
dialogue strategies to decrease litigation 9(3): 62-63
preconception care 9(4): 21-22
PCO See Polycystic ovaries
PCOS See Polycystic ovarian syndrome postnatal depression
Pelvimetry
[Q&A] 9(2): 54-55
Pelvic pain
chronic 8(3): 32-35
endometriosis and pain 9(1): 46-49
Pelvic surgery
effect on sexual dysfunction 8(3): 11-12
reconstructive surgery, future directions 7(1): 24-25
Perinatal death
holistic approach to counselling parents 11(1): 32-33
SANDS Association 7(4): 22
stillbirth, investigation of 11(1): 26-27
unexplained stillbirth 11(1): 28-31
Perinatal medicine, notable pioneers of 10(1): 26-28
Perinatal Society of Australia and New Zealand (PSANZ)
25th anniversary of 10(1): 26-28
recommended investigations for stillbirth 11(1): 28-31
Perinatal depression 7(4): 13-14
Perineal trauma
clinical practice improvement methodology 9(1): 54-55
improving womens perinea health after birth 9(2): 30-31
Peripartum cardiomyopathy (PPCM) 10(3): 25-27
Personal experiences/reflections
midwifery and obstetrician relationship 9(2): 21, 52
New Zealand trainees 9(2): 22
Plastic surgeon, perspective of breast aesthetic surgery 9(3): 31-32
PMS See Premenstrual syndrome
PND See Postnatal depression
Poistcoital bleeding [Q&A] 11(3): 54
Polynesia, emergency obstetric cases 8(2): 11
Political environment
climate change for urban obstetricians 9(2): 19, 63

Polycystic ovarian syndrome (PCOS)
gynaecology management update 7(4): 41-43
increased risks in obese adolescents 10(4): 24-25
Polycystic ovaries
factors and risks 7(4): 13-14
management update 7(4): 41-43
Polynesia 8(2): 11
Posthumous procurement
ethical considerations 9(4): 48-49
Postmenopausal
drug therapy (Tibolone) 9(1): 13-14
increased risk of coronary artery disease 10(3): 15-17
Postnatal debriefing program
Nambour General Hospital 7(4): 21
SANDS 7(4): 22
Postpartum period
sex and intimacy issues 8(3): 13-15
Post-traumatic stress disorder
following postpartum haemorrhage 11(3): 38-39
Practice, physical environment
elder friendly clinics 9(1): 11-12
issues in setting up own practice 7(2): 53-54
Practitioner
older practitioner in practice 7(2): 60-61
private practice and academia 10(1): 16, 18
Preconception care
education of women 9(4): 21-22
Pre-eclampsia
management of 8(4): 43-44
[Q&A] 10(1): 59
Pregnancy
airline pilots 8(2): 27
anaemia 11(3): 17-18
common complaints and conditions 8(4): 10-13
diabetes 8(4): 37-38
ectopic 8(4): 47
iodine supplementation 7(1): 65-66
late termination 9(4): 31-32
late termination, treatment 9(4): 33-35
loss in first trimester 9(2): 33-35
obesity, increased complications 10(4): 10-11
management of heart disease 10(3): 21-24
nausea and vomiting 9(4): 23-25
overseas travel, guidelines and advice 8(2): 28-30
physiological changes for women with pre-existing heart
conditions 11(3): 13-14
quickening [editorial] 11(2): 11
SGA pregnancies, recognition and management 9(3): 74-79
teenage 8(2): 25-26
thyroid disease 8(4): 26-27
use of hand-held Doppler machines at home 10(4): 45
Pregnancy assessment services 9(2): 33-35
Pregnancy complications
heart transplant recipients 10(3): 32-35, 24
thrombophilia 11(3): 21-23
venous thrombosis and embolism 7(4): 44-45
Pregnancy, multiple
conjoined twins 8(2): 12-13
risks and management 8(2): 36-37, 56
Prelabour rupture of membranes (PROM) 8(4): 35-36
Premature labour
use of fetal fibronectin (fFn) 8(3): 39
Premature predator rupture of membranes (PPROM) 8(4): 35-36
Premenstrual syndrome 7(4): 26-28
Preterm delivery
cervical incompetence 11(2): 30-32
92 O&G Magazine
counselling 11(2): 33-34

counselling in resuscitation issues 11(2): 33-34
Psychology
obesity issues 10(4): 21-22
Psychosexual
obstetrics and gynaecology 8(3): 27
Pubic hair, waxing or removal of 8(3): 20-21
Puberty, delayed in girls 8(3): 22-24, 35
Puerperal sepsis, historical account of 11(1): 45-46
Quickening [editorial] 11(2): 11
Radiology
interventional procedures as an alternative to gynaecological
surgery 7(1): 30-32
RANZCOG
RANZCOG Research Foundation, role of 10(1): 10-11
examination, demystifying 7(2): 36-38
FRANZCOG 9(2): 25, 74
MRANZCOG 9(2): 25, 74
obstetrical forceps collection 11(4): 19-20
RANZCOG College Statements
C-Gen 2: Guidelines for consent and the provision of
information regarding proposed treatment 8(2): 49-50
C-Gen 5: Women and smoking 8(2): 51-53
C-Gen 5: Women and smoking 10(4): 51-53
C-Gen 7 Guidelines for gynaecological examinations and
procedures 7(1): 64
C-Gen 8: Diethylstilboestrol (DES) exposure in utero 9(1): 65-66
C-Gen 9: Assessment of competency 9(1): 67
C-Gen 10: Position statement on the appropriate use of
diagnostic ultrasound 9(1): 67
C-Gen 10: Position statement on the appropriate use of
diagnostic ultrasound 11(2): 41
C-Gen 11: Postnatal/perinatal depression 9(4): 63
C-Gen12: Performance of sexual assault forensic examinations
by RANZCOG trainees 9(4): 64
C-Gen 13: Alcohol in pregnancy 10(3): 71
C-Gyn1: Guidelines for College Fellows participating in the
RANZCOG expert witness register 8(3): 53
C-Gyn 5: Screening for the prevention of cervical caner
8(3): 51-52
C-Gyn 7: Use of the Veress needle to obtain pneumoperitoneum
prior to laparoscopy 8(3): 52-53
C-Gyn 14: Mifepristone (RU846) 8(1): 52
C-Gyn 17: Termination of pregnancy 7(2): 81
C-Gyn 18: Guidelines for HPV vaccine 9(1): 68-69
C-Gyn 19: RANZCOG statement on pap smears 9(1): 69
C-Gyn20: The use of mesh in gynaecological surgery 9(3): 86
C-Gyn 21: The use of mifepristone for medical termination of
pregnancy 10(1): 81-82
C-Gyn 22: Filshie clip sterlisation 10(1): 83
C-Gyn 23: Uterine artery embolisation for the treatment of
uterine fibroids 10(2): 72
C-Gyn24: Vaginal rejuvenation and cosmetic vaginal procedures
10(3): 72
C-Gyn 25: Prophylactic oophorectomy at the time of
hysterectomy for benign gynaecological disease 11(3): 75-76
C-Obs 4: Prenatal screening tests for trisomy 21 (Down
syndrome), trisomy 18 (Edwards syndrome) and neural tube
defects 9(4): 65-69
C-Obs 6: Guidelines for the use of RhD immunoglobulin
(Anti-D) in obstetrics in Australia 8(2): 53, 59
C-Obs 11: Planned breech deliveries at term 10(1): 79-81

C-Obs 22: Use of prostaglandins for cervical ripening prior to
the induction of labour 8(3): 51
C-Obs 23: Timing of elective caesarean section 9(1): 70
C-Obs 24: Warm water immersion during labour and birth
10(3): 72-74
C-Obs 25: Vitamin and mineral supplementation in pregnancy
10(3): 74-75
C-Obs 26: Use of cervical fetal fibronectin as a screening test for
preterm birth 10(4): 53-54
C-Obs 27: Use measurement of cervical length in pregnancy for
prediction of preterm birth 10(4): 53-56
C-Obs 28: Prevention detection and management of subgenera
haemorrhage in the newborn 11(3): 70-74
C-Obs 30: RANZCOG Guideline: Suitability criteria for models
of care and indications for referral within and between models of
care 11(2): 69-75
WPI-10: Antenatal care in public hospitals 8(1): 52
WPI-14: ACRRM Position statement on the provision of obstetric
anaesthesia and analgesia services 9(2): 72-74
WPI-18: Fatigue and the obstetrician/gynaecologist 11(3): 76
WPI-16: Clinical training whilst pregnant 9(3): 87
WPI-17: Guidelines for appointment of obstetricians and
gynaecologists to specialist positions in Australia and New
Zealand 9(3): 89
REI See Reproductive endocrinology and Infertility
Religion
Anglicanism 10(2): 9-10, 8
Buddihism 10(2): 11-13
Catholicism 10(2): 14-15
editorial 10(2): 8
Indian beliefs 10(2): 16-19
Islam 10(2): 24-26
Judaism, influence of The Torah 10(2): 23
Judaism, Orthodox 10(2): 20-22
prayer, effect on reproduction 10(2): 35, 37
Reproduction
Marie Stopes International reproduction report 10(2): 38-39
Reproductive endocrinology and Infertility
curriculum and programs 7(4): 10
Reproductive issues
2026 back to 1986 8(1): 23-26
athletes, elite female 8(2): 22-23
Reproductive tract, congenital abnormalities 10(1): 54-55
Research Project, in curriculum 7(2): 30, 32
Resuscitation, neonatal 8(4): 28-29
Retirement 10(2): 64-65
RhD immunoglobulin 11(3): 19-20
Rheumatic heart disease (RHD)
effect of RHD in pregnancy 10(3): 18-20
rupture of membranes 8(4): 35-36
Rural obstetrics
academics, interactions with 10(1): 22, 24
eclampsia [Q&A] 10(1): 59
future predictions 8(1): 16-17
Northern Territory 8(2): 20-21
obese pregnancy [Q&A] 10(4): 43-44
patient presents at 31 weeks with contractions 11(1): 48-49
postpartum haemorrhage 11(3): 36-37
SANDS (Support for Parents After Early Pregnancy and Perinatal

Loss) 7(4): 22
Scientific meeting
Laos 10(3): 65-67
Scientific observations
obstetrical milestones, effect on 11(4): 12-13
Screening tests, epithelial ovarian cancer 11(4): 43-45
Selective serotonin reuptake inhibitors 7(4): 18-20

Sex chromosome aneuploidy (SCA) 11(2): 25-27
Sexual counselling
delayed puberty in girls 8(3): 22-24, 35
in females 8(3): 29, 31
intimacy after childbirth 8(3): 13-15
in males 8(3) 30-31
Sexual dysfunction
before and after pelvic surgery 8(3): 11-12
Sexual health check, older women 9(1): 22-23
Sexual history
before and after surgery 8(3): 11-12
ethics, 14-year-old teenage girl in relationship [Q&A]
10(2): 58-59
Sexuality
concerns of the older women 9(1): 24-25
female sexual desire 8(3): 9-10
in the older women 9(1): 22-23
intimacy after childbirth 8(3): 13-15
lack of arousal 8(3): 29, 31
Shoulder dystocia
management update 8(4): 48-49
Papua New Guinea, case report 11(2): 65-66
Sickle cell disease 11(3): 40-41
Small for gestational age (SGA) 9(3): 74-70
Social infertility 8(3): 25-26
South Africa 11(2): 62-63
Sports, elite
amenorrhoea, eating disorders and bone demineralisation
8(2): 22-23
Sports, extreme
pregnancy, effect on 8(2): 8-9
SSRIs See selective serotonin reuptake inhibitors
Stillbirth deaths See also Neonatal deaths
psychological debriefing for mothers 7(4): 21
examination and investigation of 11(1): 26-27
shoulder dystocia in Papua New Guinea 11(2): 65-66
unexplained 11(1): 28-31
Streptococcal infection
historical account of 11(1): 45-46
Subspecialists
collaboration between specialists and subspecialists
surgical skills training, challenge ahead 7(1): 20-21
Sudden death
of practitioner in your practice 11(1): 50-51
Surgical audits
gynaecolgical surgery 11(1): 24-25
Surgery, general
gynaecological deaths 11(1): 24-25
Swine flu 11(4): 40-1
Tamoxifen [Points of View] 7(1): 15, 80

Teenage pregnancy 8(2): 25-26
Termination of pregnancy See Abortion
Testicular function, in obese men 10(4): 34-36
Thrombophilia 11(3): 21-23
Thyroid disease 8(4): 26-27
Tibolone 9(1): 13-14
Timor Leste 11(1): 64-65
Town and gown
editorial 10(1): 9
Trainees
assessment of surgical training skills by trainees 7(1): 48

climate change 9(2): 25, 74
delivery of babies as a medical student 10(1): 33
increase in numbers 9(2): 19, 63
personal perspective on training in obstetrics 7(1): 49
preparation for College examinations 7(2): 39
research projects, personal reflections 10(1): 25
surgical skills assessment and training 7(1): 33
surgical training, education of 7(1): 34-35
trainees thoughts of the O and G curriculum 7(2): 19
Training See also Apprenticeship
apprenticeship model of O and G 7(2):14
assessment of the RANZCOG training and apprenticeship model
7(2): 15-16
disadvantages of the training and assessment of surgical skills
7(2): 18
New Zealand, moving training forward 7(2): 20
New Zealand, turning point 7(2):17
private practice, medico-legal risks 10(1): 56-57
subsequent training and practice for O and G specialists
7(2): 12-13
ultrasound skills for trainees in South Australia 7(2): 33-35
workshops in basic science, clinical medicine and technical skills
7(2): 62-63
Trainees thoughts of the O and G curriculum 7(2): 19
Travel medicine
immunisation for pregnant women 8(2): 28-30
Trisomy 21 See Down syndrome
Trophoblast invasion 9(4): 14-17
Urogynaecology
training as a subspecialty [Points of View] 7(1): 11-12
Ultrasound imaging
3D and 4D fetal imaging 11(2): 38-40
entertainment 8(4): 54-55
entertainment imaging 11(2): 38-40
hand-held Doppler machine use at home 10(4): 45
identifying fetal heart malformation at 11 to 14 weeks gestation
10(3): 36-41
identifying of fetal cardiac anomalies 10(3): 30-31
morphology scan 11(2): 35-37
obesity, problems of 10(4): 26-28
soft markers, mid-trimester 11(2): 22-24
soft markers, obstetrics management update 9(1): 45, 49
United Arab Emirates 9(3): 59-61
Urinary incontinence 11(2): 42-43
Urodynamic stress incontinence 8(1): 48-49
Vaginal delivery
caesarean, preference over [Q&A] 8(2): 71
complex or antiquated 11(4): 14-15
perineal trauma 9(2): 30-31
third degree tear and subsequent pregnancies 7(4): 38
traumatic [Q&A] 9(4): 50
vacuum extraction over forceps 11(4): 17-18
Vaginal discharge
workshop materials 9(3): 64-68
Vanimo, Papua New Guinea 11(3): 65-66
Venous thrombo-embolism (VET) 8(4): 32-34
Ventouse (vacuum extraction) 11(4): 17-18
Vestibulitis syndrome 8(3): 54-55
Vietnam, Ho Chi Minh city 10(1): 66-67
Vulval pain 8(3): 54-55
94 O&G Magazine
William Harvey 11(3): 42-44

Women, older
concerns of the older women 9(1): 24-25
domestic violence and psychological issues 7(4): 33-36
Womens Health Initiative (WHI) Randomised Trial 9(1): 20-21
Womens mental health
detention centres 7(4): 56-58
training O and G specialists 7(4): 53-55
Its not _
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REGISTER
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ADELAIDE CONVENTION CENTRE
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Contents art or science?

Available online at:

O&G Magazine Advisory Group

Obstetrics: art or science?

Editorial: Everyones a critic

Obstetrics: art or science?

Reflections on my initiation into the secret world of complex vaginal birth

Complex vaginal deliveries: Why are we still doing them?

Forceps delivery: Science wears its art on its sleeve

Preventing eclampsia: art or science?

Standards of antenatal care

Antenatal classes patient perspectives

Non-pharmacological pain management in childbirth

Planned homebirths in Australia: art, science...or politics?

Homebirth transfers at Lismore Base Hospital

A midwifes perspective on homebirth in New Zealand

Intrapartum fetal monitoring yesterday, today and tomorrow

Controlling the timing of labour: the role of progesterone and prostaglandins

Obstetric Management Update: Swine flu in obstetrics

Gynaecological Management Update: The myth of screening for epithelial

Obstetrics: art or Contents

Q&a: Management of the third stage of labour

Informed consent in labour an Australian perspective

Informed consent in labour an Australian perspective

Informed consent in labour a New Zealand perspective

Australian Capital Territory

From the President

From the CEO

Meetings Calendar Summer 2009

Fetal Surveillance: A Practical Guide a new publication

RANZCOG Practice Profile Workforce Survey

MRANZCOG Written Exam February 2009

Specialist Obstetrician Locum Scheme (SOLS) Update

Tribute to William Refshauge

RANZCOG Research Foundation 2010 Scholarships, Fellowships and Grants

Notice of Deceased Fellows

RANZCOG Womens Health Award

O&G Magazine Cumulative Index Vol 7 to Vol 11

* The next update on College Statements will be published in

The Royal Australian and New Zealand

Vol 11 No 4 Summer 2009 3

Single injection for lasting prevention

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Suite 2B, Level 2, 802 Pacific Highway Gordon NSW 2072

From the President

his will be the final Presidents report

It is fitting to start with a quote from

Working to reduce maternal mortality including unsafe abortions;

As it is the halfway point of the Sixth RANZCOG Council, the

From the CEO

t is a personal and professional

Like the practice of obstetrics, in which

Zealand, as in Australia, there appears much activity at Ministry

Like obstetrics, leading and

Zealand Parliamentarians Group on Population and Development

EPI-NO reduces the risk

Finally, as the end of the year approaches, I would like to thank

Prepares the Perineum

Contact Claudia Egli

Australian Medical Couches

Obstetrics: art or science?

think that the greatest single similarity